
Class _&iTM- 

Book L 

GopightN? 



COPYRIGHT DEPOSIT. 



A TREATISE 



ON 



ORTHOPAEDIC SURGERY 



BY 



ROYAL WHITMAN, M.D. 

Instructor in Orthopedic Surgery and Chief of the Orthopedic Department of the 
Vanderbilt Clinic in the College of Physicians and Surgeons of Columbia 
University: Adjunct Professor of Orthopedic Surgery in the New- 
York Polyclinic; Assistant Surgeon and Chief of Clinic 
at the Hospital for Ruptured and (rippled; 
Orthopedic Surgeon to the Hospital 
of St. John's GUILD. 
Member of the Royal College of Surgeons of England; Member and sometime President 
of the American Orthopedic Association; Corresponding Member of the British 
Orthopedic Society; Member of the New York Surgical Society, Etc. 



ILLUSTRATED WITH FOUR HUNDRED AND FORTY-SEVEN 

ENGRAVINGS 




LEA BROTHERS & CO. 
PHILADELPHIA AND NEW YOUK 

1901 



THE LIBRARY OF 

CONGRESS, 
Two Copies Received 

APR. 11 1901 

Copyright entry 
CLASS O'XXo. N« 

copy b. 






Entered according to the Act of Congress in the year 1901, by 

LEA BEOTHEES & CO. 
In the Office of the Librarian of Congress. All rights reserved. 



TO 

VIRGIL P. GIBNEY, M.D., LL.D. 

This Volume is Inscribed 

as a Token of Friendship Assured by Long Association, 

and of Appreciation of His Efforts 

for the Advancement of 

ORTHOPAEDIC SURGERY 



PREFACE 



The student of Orthopaedic Surgery is especially concerned with 
the mechanics of the human machine, with its development, with its 
capacity at different periods of life and under varying conditions, and 
with those affections that lead to deformity or that otherwise impair 
its usefulness. He is concerned, moreover, not only with the local and 
immediate effects of disease or disability, but also with its general in- 
fluence upon the entire mechanism, and with its ultimate consequences 
as well. 

Orthopaedic Surgery occupies a broad field and one of very great 
and general interest. Its most distinctive advance in recent years has 
been toward the prevention of deformity, an advance that has been 
made possible by the better understanding of its predisposing and ex- 
citing causes. As a natural consequence, treatment has become more 
direct, more simple, and more effective. It has been the purpose of 
the author to emphasize this aspect of the subject, which is of the great- 
est importance to the general practitioner, who so often has the oppor- 
tunity to recognize disease or disability in its incipiency, when its 
progress may be checked by timely treatment. 

He has endeavored to present Orthopaedic Surgery as far as pos- 
sible objectively, a method which has proved acceptable t6 students 
and practitioners in clinical teaching ; thus the selection of each sub- 
ject and the space that has been allotted to it has been determined 
primarily by its relative importance in the actual work of Orthopaedic 
clinics. He has been at some pains, also, to outline methods of ex- 
amination, to explain the phenomena of the symptoms and so to 
describe and to illustrate the causes and effects of disease and dis- 
ability as to indicate, in natural sequence, the principles of treatment. 
The particular methods of the application of those principles, which 
have always been described in detail, are those that have been tested 
by personal experience. 

Although this book is designed particularly for students and practi- 
tioners of medicine, the author has included statistical and other data 



vi PREFACE. 

which he hopes may prove of interest to his fellow-workers in this 
special field. 

The author desires to express his obligation to the gentlemen who 
have assisted him in the collection of statistics, and otherwise, whose 
names are mentioned in the text ; to Dr. L. W. Ely and to Mr. W. P. 
Agnew for timely photographs, and especially to the Trustees of the 
Hospital for Ruptured and Crippled, for the facilities that have been 
afforded him in the preparation of this work. R. W. 

New York, 1901. 



CONTENTS. 



CHAPTER I. 

TUBERCULOUS DISEASE OF THE SPINE. 

Description — Pathology — Etiology — Statistics — General prognosis — 
Symptoms — Physical examination — Contour and flexibility of the 
spine — Divisions of the spine — Landmarks — The differential diagno- 
sis of disease in the lower, middle and upper regions of the spine — 
Treatment by horizontal fixation — by braces — by jackets — by other 
means. The selection and adaptation of treatment for disease of the 
different regions of the spine. The complications of tuberculous 
disease of the spine — Abscess — course — symptoms — treatment. 
Paralysis — course — symptoms — treatment. Forcible correction of 
deformity — (Calot's operation) — Gradual correction of deformity. ... 17 

CHAPTER II. 

NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 

Syphilis — Malignant disease — Osteomyelitis — Actinomycosis — Injury — 
Traumatic spondylitis — Rhachitic spine — Typhoid spine — Gonor- 
rhceal "rheumatism'* of the spine — Arthritis — Spondylitis defor- 
mans — Osteitis deformans — Neurotic spine —Hysterical spine — 
Spondylolisthesis — Sciatic scoliosis — Sacro-iliac disease 107 

CHAPTER III. 

LATERAL CURVATURE OF THE SPINE. 

Description — habitual and fixed deformity, rotation and lateral devia- 
tion. Pathology — Etiology — Statistics — Varieties — Distribution 
and effects of deformity —Symptoms — Diagnosis — Prognosis — Pre- 
vention of deformity — Treatment — by exercises — general exercises 
— heavy exercises — special exercises — Supports. Forcible correc- 
tion of deformity — Adjuncts in treatment — Duration of treatment. 120 

CHAPTER IV. 

DEFORMITIES OF THE SPINE, CONTINUED. DEFORMITIES OF THE 
CHEST. FUNCTIONAL PATHOGENESIS OF DEFORMITY. 

Varieties in contour of the spine — Kyphosis — Lordosis — Congenital ele- 
vation of the scapula — Absence of vertebrae — Flat chest — Pigeon 



vm CONTENTS. 

chest — Funnel chest — Absence of ribs — Defective formation of the 
pectoral muscles — Absence or defect of the clavicle — Acquired luxa- 
tion or subluxation of the clavicle — Asymmetrical development — 
Tables of height, weight, and circumference of the chest — Functional 
pathogenesis of deformity — (Wolff's law) 181 

CHAPTER V. 

TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 

Predisposition — Mode of infection — Latent tuberculosis — Local predis- 
position — Statistics — distribution of disease — location — side affected 
— sex — age. Pathology — Varieties of disease — Method of repair — 
Prognosis — Treatment — operative and mechanical — by drugs — local 
applications — venous stasis (Bier's treatment) 194 

CHAPTER VI. 

NON-TUBERCULOUS DISEASES OF THE JOINTS. 

Syphilitic disease of joints — Gonorrhceal arthritis — Other forms of in- 
fectious arthritis — Acute epiphysitis — Localized infectious osteo- 
myelitis — Osteo- arthritis — Haemophilia — Hsemarthrosis — Scorbu- 
tus — Charcot's disease — Anchylosis 206 

CHAPTER VII. 

TUBERCULOUS DISEASE OF THE HIP JOINT. 

Pathology — Statistics — Symptoms — Physical signs, distortion, apparent 
lengthening, apparent shortening. Causes of distortion — Atrophy — 
Causes of actual shortening — Measurements — Lovett' stable— Kings- 
ley's table — Differential diagnosis — Principles of treatment — The 
traction hip brace — The Thomas brace — The plaster bandage — Vari- 
ous methods of reducing deformity — The long hip splint — Other 
forms of apparatus — Double hip disease — Abscess — statistics — treat- 
ment — Operative treatment — exploration — excision — reduction of 
resistant deformity — Prognosis, mortality, functional results. Sec- 
ondary deformities of hip disease — Final results 221 

CHAPTER VIII. 

NON-TUBERCULOUS AFFECTIONS OF THE HIP JOINT. 
Traumatisms at the hip — Acute infectious arthritis — Extra-articular dis- 
ease — Malignant disease at the hip joint — Cysts of the femur — Ar- 
thritis deformans 300 

CHAPTER IX. 

TUBERCULOUS DISEASE OF THE KNEE JOINT. 
Pathology — Etiology — Statistics — Symptoms, primary and secondary dis- 
tortions — Diagnosis — Differential diagnosis — Treatment — mechan- 



CONTENTS. ix 

ical — Extra-articular disease — Abscess — Operative treatment — 
arthrectomy — excision, amputation — Prognosis — mortality — func- 
tional results — General conclusions 304 

CHAPTER X. 

NON-TUBERCULOUS AFFECTIONS OF THE KNEE JOINT. 

Injury in childhood — Synovitis — Infectious arthritis — Osteo-arthritis — 
Prepatellar bursitis — Pretibial bursitis — Bursse and cysts in the 
popliteal region — Internal derangement of the knee joint — Con- 
genital genu recurvatum — rudimentary or absent patella — Con- 
genital displacement of patella — Slipping patella — Elongation of the 
ligamentum patellae — Snapping knee — Congenital contraction at the 
knee — General contractions — Acquired genu recurvatum 324 

CHAPTER XL 

DISEASES AND INJURIES OF THE ANKLE JOINT. 

Tuberculous disease — Pathology — Etiology — Statistics — Symptoms— Di- 
agnosis — Treatment — Prognosis — Tuberculous disease of the tarsus 
— Statistics — Treatment — Sprain of the ankle — Teno-synovitis — 
Other affections of the ankle joint 334 

CHAPTER XII. 

DISEASES AND INJURIES OF THE ARTICULATIONS OF THE 
UPPER EXTREMITY. 

Tuberculous disease of the shoulder joint — Pathology — Statistics — 
Symptoms — Treatment — Prognosis — Tuberculous disease of the el- 
bow joint — Pathology — Statistics — Symptoms — Treatment — Prog- 
nosis—Tuberculous disease of the wrist joint — Symptoms — Treat- 
ment — Prognosis — Spina ventosa — Periarthritis of the shoulder 
joint — Chronic bursitis at the shoulder — Sprain of the wrist — 
Acute teno-synovitis at the wrist 348 

CHAPTER XIII. 

CONGENITAL AND ACQUIRED AFFECTIONS LEADING TO 
GENERAL DISTORTIONS. 

Rhachitis — Etiology — Pathology — Symptoms, deformities — Prognosis — 
Treatment — "Late rickets" — "Fcetal rhachitis" — Infantile scorbu- 
tus — Fragilitas ossium — Osteomalacia — Osteitis deformans — Secon- 
dary hypertrophic osteo-arthropathy — Acromegalia 361 

CHAPTER XIY. 

CONGENITAL DISLOCATION OF THE HIP AND COXA VARA. 

Congenital dislocation of the hip joint — Statistics — Pathology — Etiology 
— Symptoms — Diagnosis — Differential diagnosis — Treatment — the 



x CONTENTS. 

open operation — the Lorenz operation — the intermediate operation — 
secondary osteotomy — Palliative treatment — Coxa vara — Pathology 
— Etiology — Statistics — Symptoms — Diagnosis — Treatment — me- 
chanical — operative. Fracture of the neck of the femur — Trau- 
matic separation of the epiphysis of the head of the femur 373 

CHAPTER XV. 

DEFORMITIES OF THE BONES OF THE LOWER EXTREMITY. 

Bow leg — Knock knee — Statistics — Etiology — The outgrowth of defor- 
mity — Genu valgum — Description — Attitudes — Secondary defor- 
mities — Gait — Unilateral deformity — Pathology — Treatment — 
expectant — mechanical — operative — Genu varum, Varieties — 
Symptoms — Treatment — Expectant — mechanical — operative — An- 
terior bow leg — General rhachitic distortions 405 

CHAPTER XVI. 

DEFORMITIES OF THE UPPER EXTREMITY. 

Congenital dislocation of the shoulder — Obstetrical paralysis — Recur 
rent dislocation of the shoulder — Congenital deformities of the 
elbow — Cubitus valgus — Cubitus varus — Subluxation of the wrist — 
Club hand — Varieties — Club hand associated with defective devel- 
opment — Congenital contraction of the fingers — Webbed fingers — 
Trigger finger — Mallet finger — Baseball finger — Dupuytren's con- 
traction 430 

CHAPTER XVII. 

DISEASES OF THE NERVOUS SYSTEM. 

Acute anterior poliomyelitis — Pathology — Etiology — Statistics — Symp- 
toms — Causes of deformity — Deformity iu various regions — Sublux- 
ation — Retardation of growth — Treatment, mechanical, operative... 440 

CHAPTER XVIII. 

DISEASES OF THE NERVOUS SYSTEM, CONTINUED. 

Cerebral paralysis of childhood — Description — Distribution — Etiology — 
Pathology — Symptoms — Congenital paralysis — Acquired paralysis 
— Treatment — Prognosis — Progressive muscular atrophy — Varieties 
— Symptoms — Hereditary ataxia — Neuritis — Functional affections 
of the joints — " Hysterical " hip — Differential diagnosis — " Hyster- 
ical ' ' club foot — u Hysterical ' ' scoliosis — Neurotic joints 459 

CHAPTER XIX. 

CONGENITAL AND ACQUIRED TORTICOLLIS. 

Description — Statistics — Congenital torticollis — Eti ology — Hsematoma of 
the sterno-mastoid muscle — Acquired torticollis — Varieties — Acute 



CONTENTS. xi 

torticollis — Etiology — Symptoms — Diagnosis — Treatment of torti- 
collis — chronic, acute — Spasmodic torticollis — Etiology — Pathology 
— Treatment — Exceptional forms of torticollis — paralytic — diphthe- 
ritic — cervical opisthotonos, rhachitic — ocular — psychical 474 



CHAPTER XX. 

DISABILITIES AND DEFORMITIES OF THE FOOT. 

General description of the foot and of its functions, the arches, the foot 
as a passive support, in activity — Improper postures — Movements 
— Function of the muscles — Strength of the muscles — The foot as a 
mechanism — The weak foot or so-called flat foot — Description — 
Anatomy — Pathology — Etiology — Statistics — Symptoms — Diagnosis 
— Varieties — Weak foot in childhood — Treatment, preventive — 
Exercises — Support — Construction of brace — The rigid weak foot — 
Forcible correction of deformity — Subsequent treatment — Adjuncts 
in treatment — Operative treatment . 492 



CHAPTER XXL 

DISABILITIES AND DEFORMITIES OF THE FOOT, CONTINUED. 

The hollow foot — Anterior metatarsalgia — Achillo bursitis — Achillo- 
bursitis posterior — Strain of the tendo Achillis — Calcaneo-bursitis 
— Plantar neuralgia — Erythromelalgia — Hallux rigidus — Hallux 
varus — Pigeon toe — Hallux valgus — Hammer toe — Overlapping 
toes — Exostoses — Displacement of the peronei tendons — Shoes, 
effects of improper shoes — Demonstration of the proper shoe 530 



CHAPTER XXII. 

DEFORMITIES OF THE FOOT. 

Talipes — Description — Varieties — Statistics of talipes, congenital and 
acquired — Relative frequency of the different varieties — Congenital 
talipes — Etiology — Anatomy — Symptoms — Principles of treatment 
of infantile club foot — Treatment — mechanical — by plaster band- 
age — by braces— restoration of function — supervision — Treatment 
in older subjects — forcible manual correction — tenotomy — Wolff ? s 
treatment, reduction of deformity by wrenches — Phelps' operation 
— Operations on the bones — Mechanical treatment — Other varieties 
of congenital talipes — varus — equinus — calcaneus — valgus — equino- 
valgus — calcaneo-valgus — calcaneo-varus — equino-cavus — valgo- 
cavus — cavus— Congenital talipes associated with defective develop- 
ment — with absence of fibula — with absence of tibia — with defective 
formation of the foot— Constricting bands — Congenital amputation 
— Congenital oedema — Spina bifida and talipes '. 560 



xii CONTENTS. 

CHAPTER XXIII. 

DEFORMITIES OF THE FOOT, CONTINUED. 

Acquired talipes — Etiology — Diagnosis — Talipes equinus — Description — 
Etiology — Symptoms — Treatment — mechanical— operative— Talipes 
calcaneus — Description, development of deformity— Symptoms — 
Treatment — mechanical, operative — Willett's operation — astraga 
lectomy — Talipes equino-varus and talipes equino valgus — Other 
varieties of acquired talipes — Tendon transplantation in the treat- 
ment of paralytic talipes — Tendon splicing — Arthrodesis 609 



Orthopaedic Surgery. 



CHAPTER I. 

TUBERCULOUS DISEASE OF THE SPIKE. 

Synonym. — Pott's Disease. 

Pott's disease is a chronic destructive ostitis of the bodies of the ver- 
tebrae which form the anterior or weight-supporting portion of the spinal 
column. As the disease progresses the spine bends at the weakened 
point, and the upper part, sinking downward and forward, throws into 
relief the spinous processes at the seat of disease ; thus an angular 
posterior projection is formed. It is called Pott's disease because such 
deformity, slow in formation, accompanied by pain and sometimes by 
paralysis, was first described accurately by Percival Pott, in 1779. 
Angular deformity is, however, simply the evidence of destruction of 
a portion of the anterior part of the vertebral column. Thus it might 
be the result of fracture, or of the erosion of an aneurism, or of malig- 
nant disease, or syphilis or other pathological process ; but deformity 
from such causes is not now included under Pott's disease, nor is the 
term now synonymous with deformity. In the modern sense it signi- 
fies tuberculous disease of the bodies of the vertebra?, of which the 
early symptoms may be detected and of which the deforming effects 
may be checked and even prevented by proper treatment. The com- 
pression and collapse of the affected parts cause the characteristic 
angular projection at the seat of disease. If one vertebral body is 
destroyed the projection will be sharp ; if several are implicated it 
will be less angular, and if one side of a body breaks down before the 
other there may be a lateral as well as a posterior distortion. 

The size of the deformity and its effect upon the individual depend 
in great degree upon its situation. If the disease is at either extremity 
of the spine the angular projection must be small because so little of 
the column remains beyond the destructive process ; or in other words, 
the area of the spine directly involved in the deformity is small com- 
pared to that which is free from disease. Thus the characteristic de- 
formity in the upper cervical region shortens the neck and disturbs 
the poise of the head ; in the lower lumbar region it shortens the 
trunk and induces a peculiar attitude and gait. In either case the 
actual local deformity is usually insignificant and the distortion of the 
body is comparatively slight. But when the middle of the spine is 
involved, the opportunity for deformity is great because the entire 
2 



18 



TUBERCULOUS DISEASE OF THE SPINE. 



Fig. 1. 



column may enter into the formation of the angular kyphosis ; thus 
the internal organs are compressed and the effect upon the vital mech- 
anism is disastrous. 

Pott's disease, as contrasted with tuberculosis of other bones and 
joints, is peculiar in that it is concealed from view, in that direct sur- 
gical intervention is of comparatively little avail, in that it lies in 
close proximity to important parts, the spinal cord behind and the 
vital organs in front, and finally, in that the effects of the disease and 
deformity are not limited to the parts directly involved, but influence, 
to a greater or less degree, the entire mechanism 
of the body. 

Pathology. — The minute changes that char- 
acterize tuberculosis of bone in general are de- 
scribed in Chapter V. 

The first indication of the disease is usually 
found in the anterior part of a vertebral body 
just beneath the fibro-periosteal layer of the an- 
terior longitudinal ligament. From this point 
the granulation tissue advances along the front of 
the spine and, following the course of the blood 
vessels, it invades and destroys the adjacent ver- 
tebral bodies. In other instances the disease 
may begin in the interior of a vertebral body, 
most often in several minute foci near the upper 
or lower epiphysis. These coalescing, gradually 
enlarge, forming a cavity, surrounded for a time 
by unbroken cortical substance, which becoming 
weaker collapses under the pressure of the super- 
incumbent weight. Occasionally the disease ad- 
vances beneath the anterior ligament without 
implicating deeply the substance of the bone, a 
form of tuberculous periostitis, " spondylitis 
superficialis." 

The inter-vertebral discs appear to offer some 
resistance to the extension of the disease from 
one vertebra to another, but when the bone is de- 
stroyed on either side they quickly disintegrate 
and disappear. The posterior part of the spinal 
column usually remains practically free from disease with the excep- 
tion of the pedicles and articulations which may be in direct contact 
with the tuberculous process. In rare instances the disease may begin 
in a lamina or spinous process, or one of the small joints may be 
primarily involved, but such forms of local tuberculosis would hardly 
be classed as Pott's disease unless the anterior part of the spine were 
implicated also. 

The course and outcome of the disease depends upon its type. In 
one instance the area of primary infection is small and the local re- 
sistance is sufficient to check its further progress, so that cure without 




Destruction of the bodies 
of the first, second and third 
lumbar vertebrae — with the 
resulting deformity. (Me- 
nard.) 



PATHOLOGY. 19 

deformity may follow ; or it may advance slowly, accompanied by a 
process of repair ; the area of active disease is small and the granula- 
tion tissue undergoes a fibroid transformation or becomes ossified. In 
such cases deformity may appear and slowly increase, practically with- 
out symptoms. In most instances however, the tuberculous granula- 
tions advance more rapidly, destroying the bone or other tissue with 

Fig. 2. 




Pott's disease. 



which they come in contact ; the usual retrograde metamorphosis to 
cheesy degeneration follows and very frequently liquefaction or abscess 
formation ; the latter change being caused possibly by secondary in- 
fection with pyogenic germs. Clinically the liability to abscess is 
very much increased by irritation or injury and is decreased by abso- 
lute rest of the diseased part. 



20 TUBERCULOUS DISEASE OE THE SPINE. 

As a rule, in those cases of moderate severity, that come to autopsy 
during the progressive stage of the disease, one finds on dividing the 
thickened tissues in front of the spine, a cavity, the walls of which are 
lined with tuberculous granulations in various stages of degeneration, 
and containing puriform fluid. The adjoining vertebral bodies pre- 
sent a worm-eaten appearance and one or more of them is partially 
destroyed. Small fragments of necrosed bone and " bone sand " may 
be present, together with larger masses of degenerated tissue ; in rare 
instances sequestra of considerable size may be found. 

Occasionally the disease may begin in the posterior part of a verte- 
bral body, or it may extend backward as well as forward, and, forcing 
its way into the vertebral canal, it may press upon the spinal cord and 
involve its coverings, and thus cause paralysis of the parts below. 
Less often pressure on the cord may be due to the presence of an 
abscess or to a projecting fragment of bone. 

The calibre of the spinal canal may be constricted somewhat by the 
pressure of the superincumbent weight upon the softened and thick- 
ened tissues at the seat of disease, but as a rule, its capacity is not 
directly lessened by the angular distortion nor does the degree of de- 
formity directly influence the frequency of paralysis. 

Although the disease may begin in multiple primary foci of infection 
over an extended area, or in two or more distinct regions of the spine 
simultaneously, yet clinical observation seems to show that it is, in 
most instances, originally confined to one or two adjacent bodies, one or 
both of which are partially destroyed ; from this central point the dis- 
ease may extend in either direction until half the spine may be impli- 
cated, but in ordinary cases the final area of deformity and rigidity 
shows that from three to six bodies are more or less involved before 
cure is established. 

If the disease is limited in extent, the eroded surfaces of the adjoin- 
ing vertebrae may come into direct contact, but if several vertebral 
bodies have been destroyed the upper portion of the spine as it sinks 
downward is often displaced backward so that the anterior aspect of 
one or more of the upper segments may be apposed to the superior 
surface of the first body of the lower section (Fig. 3). Less often there 
may be forward displacement of the upper part upon the lower (Fig. 1). 

At all stages of the disease resistance to its progress, and efforts at 
repair are evident in the affected parts. When this resistance over- 
balances the tendency to degeneration, cure follows. 

Repair is accomplished occasionally by contact and solid union of 
the adjoining surfaces of softened bone, but usually the anchylosis is 
in part fibrous, in part cartilaginous and in part bony, and this union 
may be further strengthened by a callous formation from the thickened 
tissues about the seat of disease. 

In many instances the articular processes, the pedicles and laminae 
become anchylosed before repair has advanced appreciably in the an- 
terior portion of the column. 

Cure may be absolute, as when no vestige of the disease remains ; 



ETIOLOGY. 



21 



it may be practically complete, as when the diseased products undergo 
calcareous degeneration and are shut in by a layer of solid bone. In 
other instances the disease becomes quiescent or but slowly advances, 
showing its presence by exacerbations of pain or by the formation of 
an abscess, long after active symptoms have ceased. 

Etiology. — The etiology of tuberculosis of the spine does not differ 

Fig. 4. 



Fig. 3. 




Destruction of the bodies of the third, 
fourth, fifth, sixth and seventh dorsal verte- 
brae ; partial destruction of three others. 
(Menard.) 



The deformity corrected shewing the area 
of the destructive process. (Menard.) 



from that of tuberculosis of other bones ; the subject is considered 
in Chapter V. 

Relative Frequency. — Tuberculosis of the spinal column is more 
common than of any other single bone or joint, as might be ex- 
pected from its greater area. This point is illustrated by the. sta- 
tistics of tuberculous disease treated in the out-patient department of 



22 TUBERCULOUS DISEASE OF THE SPINE. 

the Hospital for Ruptured and Crippled, New York, during a period 
of fifteen years, 1885-1899. 

Tuberculosis of the Spine 3,207 cases. 

" " " Hip 2,230 " 

" " other joints inclusive 2,408 " 

Also by similar statistics contained in a recent report of the Boston 
Children's Hospital, for a longer period, 1869-1893. 

Tuberculosis of the Spine 1,864 cases. 

" " Hip, Knee, Ankle, 
Shoulder, Elbow and Wrist combined 1,856 " 

Age. — Pott's disease, although far more frequent in the middle 
period of childhood, from the third to the tenth years, may occur at 
any time from earliest infancy to extreme old age. 

In a series of 1,259 consecutive cases of tuberculosis of the spine 
collected from the records of the outdoor department of the Hospital 
for Ruptured and Crippled, New York, analyzed for me by Drs. R. 
T. Frank and C. Gunter, the ages of the patients at the supposed time 
of onset of the disease appeared to be as follows : 

Less than 1 year 38 3.1 per cent. 

Between land 2 years 176 14.2 " 

" 3 " 5 " 627 50.2 " 

" 6 " 10 " 234 18.3 " 

11 " 20 " 89 7.2 " 

" 21 " 30 " 43 3.5 

" 31 " 50 " 31 2.6 " 

Over 50 " 11 8 " 

The youngest patient was two months old, the oldest seventy-one years. 

Dr. Thorndike, 1 of Boston, from the records of the Boston Children's 
Hospital for thirteen years, 1883 to 1896, collected 115 cases of tuber- 
culosis of the spine in children of two years or less. Seven of these 
were less than six months, and twenty were under one year in age. 

Mr. Howard Marsh 2 has called attention to Pott's disease of the 
aged, and cites three cases in subjects of sixty or more years of age. 

Sex. — Sex exercises comparatively little influence on the liability to 
disease of this region. Of 3,797 cases collected by Mohr, Gibney, 
Fischer, Taylor and Bradford and Lovett, quoted by Hoffa, 2,045 
were in males and 1,752 were in females. Of 1,367 cases collected 
by Frank and Gunter, 708 (52 per cent.) were in males and 659 (48 
per cent.) were in females ; and in 2,455 cases tabulated by Knight 
1,329 were in males and 1,126 in females. In these combined cases 
from the Hospital for Ruptured and Crippled 3,822 in. number, 53.2 
per cent, were in males and 46.8 per cent, in females. 

The Situation of the Disease. — The dorso-lumbar section of the 
spine is most often affected. Cervical ostitis is comparatively infrequent. 

In the series of 1,355 cases from the records of the Hospital for 

1 Trans. Am. Ortho. Ass'n, Vol. IX., 1896. 

2 Ibid., Vol. IV, 1891. 



THE SITUATION OF THE DISEASE. 23 

Kuptured and Crippled, the attempt was made to locate the origin of 
the disease by the most prominent spinous process in the tracing. 
The following are the conclusions. 



Cervical. 


Dorsal 




Lumbar. 


Lumbo-sacral. 


1st. ...... 


.. 3 


1st 


. 26 


1st.. 


94 


13 


2d 


. 3 


2d 


. 43 


2d.... 


96 




3d 


..15 


3d 


. 42 


3d.... 


64 


No Deformity. 


4th 


...20 


4th 


. 46 


4th... 


57 


Cervical 2 


5th 


,..13 


5th 


. 49 


5th .. 


6 


Dorsal 31 


6th 


..22 


6th 


. 76 




317 


Lumbar 22 


7th 


..24 

loo 


7th 

8th 


. 82 
. 97 






1*5 






9th 


. 92 




Disease in 


two regions of the spine, 






10th 


.110 






16 






11th 


. 71 












12th 


.120 









854 

Similar statistics are recorded by Julius Dollinger, 1 of Budapesth, of 
700 cases of Pott's disease. Of these the situation of the primary dis- 
ease could be ascertained in 538. Of this number, in 63 the disease was 
of the cervical, in 321 of the dorsal and in 154 of the lumbar region. 

The relative frequency of disease of the different dorsal and lumbar 
vertebrae, was as follows : 



Dorsal. 




Lumbar. 


1st... 


.. 6 


1st 59 


2d. .. 


.. 7 


2d 37 


3d 


..12 


3d 31 


4th 


-10 


4th 17 


5th 


..19 


5th 10 


6th 


..17 


154 


7th 


..33 




8th 


..36 




9th 


..36 




10th 


..43 




11th 


..38 




12th 


...64 





321 

The proportionate length of the different sections of the spine at the 
age of five years is, according to Professor Disse (Skeletlehre, 1896) : 

Cervical 20.2 

Dorsal 45.6 

Lumbar 34.2 

100.0 

If this be contrasted with the percentage of the cases of disease of 
each section, it will show that the frequency of the disease in the dif- 
erent regions of the spine does not correspond to the area, as has been 
suggested, but that it is proportionately much less frequent in the cer- 
vical and much more frequent in the dorsal region ; a frequency that 
may be explained by the greater strain to which the middle and lower 
1 Die Beliandlung der Tuberculosen Wirbelentzundung. Stuttgart, 1896. 



24 TUBERCULOUS DISEASE OF THE SPINE. 

part of the spine is subjected, as well as by the relative proportion of 
cancellous tissue which offers the opportunity for infection. 

Dollinger. Frank and Gunter. 

Cervical 11.7 per cent. Cervical 7.6 per cent. 

Dorsal 59.6 " " Dorsal 66.1 " " 

Lumbar 28.6 u " Lumbar 26.2 " " 

Prognosis. — The prognosis in tuberculous disease is discussed in 
Chapter V. : Pott's disease is the most dangerous of all the tuberculous 
affections of the bones or joints, as would be expected from the rela- 
tive importance of the structure affected and of the parts lying in 
contact with it. 

It is evident also that the amount of deformity, and its situation, 
have a direct influence on the prognosis. 

In the typical " hump-back " deformity, the contents of the thorax 
and abdomen are necessarily compressed, the blood-vessels are dis- 
torted and the calibre of the aorta is thereby often much diminished. 
Respiration is made difficult, and the circulation is impeded, so that the 
heart is usually hypertrophied and valvular insufficiency is not infre- 
quent ; thus the vital functions, which are carried on at a disadvan- 
tage even under favorable conditions, become impossible under the 
added strain of unfavorable surroundings, overwork or disease. It 
is a matter of common observation also that few of those who are 
markedly deformed reach old age. On the other hand, it may be as- 
sumed that slight deformities, or those which do not as directly inter- 
fere with the vital functions, exercise but little influence upon the 
future well-being of the patient. 

Although the absolute mortality of Pott's disease cannot be accu- 
rately estimated, it may be stated that at least 20 per cent, of all 
patients die during the progress of the disease and within a few years 
after its onset, from causes directly or indirectly dependent upon the 
local lesion. Some of these die from general dissemination of the 
tuberculous infection and tuberculous meningitis ; some from exhaus- 
tion following septic infection and long-continued suppuration, or from 
amyloid degeneration of the internal organs ; some, from tuberculosis 
of the lungs, and many, from intercurrent affections that are fatal be- 
cause of the devitalizing influence of the disease and its complications. 

The prognosis of Pott's disease, in the individual case, is influenced 
by many considerations. In one instance the family history isgood, 
the surroundings are favorable, the patient is in good condition and the 
disease is in the early stage ; one is then inclined to look upon it as 
an accident, and hardly considers the possibility of a fatal termination. 
While in another case, the weakness and under-vitalization of the 
body are so evident, that the affection of the spine seems but an in- 
cident of a general degeneration. 

Symptoms. — The most distinctive sign of Pott's disease is deform- 
ity. At an early stage of the process there may be but a slight irreg- 
ularity in the contour of the spine, and if several adjacent vertebral 



SYMPTOMS. 25 

bodies are affected the projection may be somewhat rounded in out- 
line. Bat, as compared with other deformities of the spine, that of 
Pott's disease is characteristically angular, and as its cause is loss of 
substance, its formation is accompanied by and must have been pre- 
ceded by the symptoms of bone disease. 

Deformity is thus the evidence of a destructive process that may 
have existed for weeks or months even, and only by its early recogni- 
tion can the ideal result, the prevention of deformity, be attained. 
For the spine which, although weak, is still straight may be kept 
straight, but when the deformity is present, it can be remedied only in 
part, and it may be difficult even to check its further progress. For 
as the upper segment of the spine sinks forward and downward, the 
influences of compression and attrition increase the activity of the local 
process and aggravate its effects. 

Angular deformity has been long considered as the essential sign of 
Pott's disease, and even now, the fact is not generally recognized that 
the detection of tuberculous ostitis of the spine in the early stage, is 
both possible and easy by the same methods that serve for the diag- 
nosis of other affections, not attended by such obvious symptoms as 
external deformity. It is to such application of the principles of dif- 
ferential diagnosis that attention is especially called. 

As the spine is the chief support of the body and as it allows a free 
mobility that accommodates it to every movement of the trunk and to 
every motion of the limbs even, it is evident that the symptoms of a 
destructive ostitis must be pain, weakness, and impairment of normal 
motion. Motion and support are not, however, the only functions of 
the spine ; it contains the spinal cord, from which branch the nerves 
that supply the organs and members of the body. This may be im- 
plicated even at an early stage of the affection, and the sudden onset 
of paralysis may overshadow the symptoms of original disease. Or 
the tumor of an abscess, one of the common accompaniments of tuber- 
culous disease of bone, may interfere with the functions of important 
parts lying in the neighborhood of the spine, thus peculiar symptoms, 
due to this cause, may attract attention before the primary disease is 
suspected. These are symptoms that may be misleading and it is well, 
therefore, to consider them apart from those that indicate the primary 
effect of the disease upon the spine, considered as an elastic support. 
These direct symptoms usually precede, and always accompany the sec- 
ondary or complicating symptoms, and upon them the diagnosis depends. 

The primary and diagnostic symptoms of Pott's disease 
may be classified as follows : 

(a) Pain. 

(b) Stiffness. 

(c) Weakness. 

(c?) Awkwardness. 
(e) Deformity. 

(a) Pain. — At first thought, one might expect the pain of Pott's 
disease to be localized at the affected vertebrae, and to be accompanied 



26 



TUBERCULOUS DISEASE OF THE SPINE. 



Fig. 5. 



by sensitiveness to pressure or even by infiltration and swelling of the 
tissues, but it will be remembered that the bodies of the vertebrae are 
in the interior of the trunk, practically speaking, as near to its anterior 
as to its posterior surface (Fig. 9) and that the 
products of the disease pass downward and 
forward, rarely backward. 

Thus sensitiveness to pressure on the project- 
ing spinous processes is unusual, and palpation, 
except in the cervical region, is of compara- 
tively little diagnostic value. 

The pain of Pott's disease is not localized 
in the back, in the neighborhood of the dis- 
ease, because the nerve filaments that supply 
the bodies of the vertebrae are insignificant 
parts of nerves that are distributed to distant 
points, to the head, to the legs, to the front and 
sides of the body and to these parts the pain 
is referred; thus "earache" or " stomach-ache" 
or " sciatica "may be symptomatic of Pott's 
disease of the different regions of the spine. 

The pain of Pott's disease is by no means 
constant, it is induced by jars or by sudden or 
unguarded movements. It is often worse at 
night, when after the relaxation of the muscu- 
lar spasm that has protected the part, the un- 
conscious movements during sleep cause dis- 
comfort or pain and the child moans in its 
sleep, or is restless, and sometimes it wakes 
with a cry — " night cry." 

(b) Impairment of Function or Loss of Normal 
Mobility — Stiffness. — Stiffness of the spine, the result of the destructive 
ostitis, is in part voluntary, in the sense that the patient adapts his 
movements and attitudes to the disease and pain and thus avoids, if 
possible, strain and jar — but the essential and characteristic stiffness 
of Pott's disease is caused by the involuntary muscular tension and 
contraction of the muscles about the seat of disease. This reflex mus- 
cular spasm varies in degree, according to the state of the underlying 
disease. It may fix the spine or it may be evident only at the extremes 
of motion, but it is always present, preceding deformity and accom- 
panying it until cure is established ; thus it is the most important of 
the diagnostic symptoms of Pott's disease. 

(c) Weakness. — As the disease affects the most important support 
of the body, it is a direct as well as an indirect cause of weakness, 
and the more vulnerable the spine, the more pronounced is this symp- 
tom ; thus in the young child, whose spine is in great part cartilaginous, 
evidence of weakness is shown by the "loss of walk," the refusal to stand 
or the instinctive desire for support, at an early stage of the disease. 

(d) Change in Attitude — " Awkwardness." — This really sums up the 




A, direct deformity 

pensatory deformity. 



B, com- 



SYMPTOMS. 



27 



effects of the preceding symptoms, since it is evident that pain, weak- 
ness, and rigidity must cause a change in the appearance and in the 
habitual attitudes of the patient. Such symptomatic attitudes may be 
almost diagnostic of the disease and of the part of the spine involved. 
(e) Change in the Contour of the Spine — Deformity. — The deformities 
of Pott's disease may be classified as follows : 

1. Bone deformity. 

2. Muscular deformity. 

3. Compensatory deformity. 

The characteristic angular projection due to destruction of bone has 
been described already. 

Muscular deformity is the distortion due to muscular spasm or con- 
traction. Of this, the wry neck, symptomatic of cervical disease, and 



Fig. 6. 




Normal contour and flexibility of the spine. 



psoas contraction in the lower region of the spine, are the most familiar 
examples. 

Compensatory deformity signifies the more general effect of the local 
-disease and local distortion, upon the spine as a whole. (Fig. 5.) Thus 
an angular projection must be balanced by a compensatory incurvation, 
and lateral distortion in one direction by lateral distortion in another. 
These deformities are, of course, nearly related, and they are usually 
combined, although muscular distortion may precede the stage of bone 
destruction, while the compensatory changes are not immediately ap- 
parent. These general and secondary changes in contour may catch 
the eye before the primary local deformity is detected. 

Lateral deviation of the spine is not infrequent ; it may be direct 
distortion at the seat of disease, caused by the destruction of the side 
of a vertebral body, but more often it is a secondary effect of such 



28 



TUBERCULOUS DISEASE OF THE SPINE. 



irregular erosion at one or the other extremity of the spine, or the 
effect of muscular contraction, or it may be clue to simple weakness. 

Finally, even at a much earlier stage of the disease, there is, almost 
always, a slight change in the outline of the spine due to local rigidity ; 
thus the spine no longer forms a long regular curve when the body is 
bent forward, but as one section remains more or less rigid while the other 
bends, the outline is broken at or near the seat of the disease. (Fig. 7.) 

Secondary or Complicating Symptoms. — (a) Abscess. — This may, 
by its size or situation, cause peculiar symptoms. In the retro-pharyn- 



Fig. 7. 











ri 


HP\ 




r / JJ^H 










|\ | 


Sj 



Incipient Pott's Disease. Showing the break in the contour of the spine, of which the normal 
flexibility is but slightly impaired. 



geal space it may interfere with respiration and deglutition. In the 
thoracic region it might be mistaken for pleurisy or empyema, and when 
it forms a tumor in the iliac fossa, it may interfere with locomotion. 

(6) Paralysis. — This is usually a late symptom, but if the disease 
begins in the center or posterior part of a vertebral body it may im- 
plicate the spinal cord before deformity is apparent. 

Abscess and paralysis are symptoms that may be explained by Pott's 
disease, but other than by calling attention to disease of the spine as a 
possible cause of the complication, they do not aid one in determining 
the diagnosis ; for this reason they are classed as secondary symptoms. 



CONTOUR AND FLEXIBILITY OF THE NORMAL SPINE. 29 

General Symptoms. — By some surgeons, especial stress is laid upon 
the diagnostic value of a slight but constant elevation of the tempera- 
ture. This is usually present if the disease is active or when an ab- 
scess is approaching the surface, but the positive value of the symptom 
in early or quiescent cases, is doubtful. One may expect also that a 
patient suffering from tuberculous disease of the spine will present 
some evidence of a painful and depressing affection, or some evidence 
of inherited or acquired weakness, yet it must be remembered that the 
absence of such general symptoms would not exclude Pott's disease. 

The Contour and Flexibility of the Normal Spine. 

In the enumeration of the early symptoms of Pott's disease, two 
have been noted as of especial importance : the impairment of normal 
mobility and the effect of the disease upon the contour of the spine 
and upon the attitudes of the patient. Therefore, in the study of the 
normal spine, the standard with which that suspected of disease must 
be compared, mobility and contour, at different ages, and under differ- 
ent conditions, should receive especial consideration. 

Although the spine as a whole is a flexible column, yet it has a 
fixed contour ; it curves forward in the upper, backward in the mid- 
dle, and forward again in the lower region. These curves are, in great 
degree, the effect of the force of gravity and of the action of the 
muscles in balancing the weight of the body in the upright attitude. 
In the adult they are practically permanent ; in early childhood they 
can be nearly obliterated by traction in the horizontal position ; and 
in infancy they do not exist. If the newborn infant be placed in the 
sitting posture the head falls forward and the spine bends in one long 
backward curve characteristic of weakness. If it be placed on the 
back and the legs be drawn down from their habitual attitude of semi- 
flexion, it will be noticed that the range of extension is somewhat 
limited because of the absence of the lumbar curve and inclination of 
the pelvis. When the gain in muscular power has been sufficient to 
enable the infant to raise and control the head the curve of the neck 
appears. Later when the child stands the erector spinse muscles hold 
the body upright against the resistance of the ilio psoas group and of 
the ligaments of the hip joint ; thus the lumbar curve and the incli- 
nation of the pelvis result and the normal contour of the spine is 
established. 

If from the odontoid process of the axis of a normal individual in 
the erect posture a line be dropped to the ground, this perpendicular 
or weight line, about Avhich the weight of the body is balanced, will 
indicate the curves of the spine, and divide it into sections that corre- 
spond sufficiently well to function. The cervical curve ends at the 
second dorsal, the thoracic curve at the twelfth dorsal and the lumbar 
curve at the sacro- vertebral angle. (Fig. 8.) 

What has been spoken of as the normal contour of the spine varies 
considerably in the adult. It is affected by the occupation, and many 



30 



TUBERCULOUS DISEASE OF THE SPINE. 



Fig. 8. 



other circumstances ; of this, the round shoulders of the cobbler or 
the weaver, the stoop of weakness, of old age and the like are familiar 
examples : but in childhood, distinct variations from the normal con- 
tour almost always have a clearly denned 
pathological cause. As the normal contour 
is the effect of the balancing of the body in 
the upright posture, it is evident that if the 
outline of one part is permanently changed, 
compensation for this change must be made 
in another part. Thus when deformity is 
well marked, the normal curves of the spine 
are often completely reversed (Fig. 5), and 
even at an early stage of the disease, the 
abnormal contour will often attract atten- 
tion, long before the characteristic angular 
projection has become apparent. 

Although the spine is a flexible column 
that is constantly changing in outline with 
every movement and posture yet the range 
and character of this motion vary greatly in 
its different parts. In the cervical and lumbar 
regions motion is extensive, because of the 
relatively large proportion of elastic inter- 
vertebral substance, because of the direction 
of the articular surfaces, and because the 
center of motion is near the middle of the 
body. Motion is very limited in the thoracic 
region, because the intervertebral discs are thin, because of the over- 
lapping spinous processes and because it forms a part of the rigid 
thorax. Where free motion is essential to the habitual attitudes, there 
disease, which interferes with normal motion, will be earliest apparent, 
in awkwardness, weakness, and pain, and there, muscular spasm, the 
chief cause of the rigidity and restraint of normal motion, will be 
evident on examination. 

Thus one more often has the opportunity to make an early diagnosis 
in disease of the lumbar and cervical regions, because in the one the 
motions necessary in stooping, sitting and standing are constrained, 
and in the other the neck is stiff, or the head is turned or drawn from 
the normal line. In the thoracic region, early diagnosis is less often 
made, because in this section motion is so unimportant that its restraint 
may escape the attention of the patient or parent. Thus, in consider- 
ing early diagnosis, and in fact, treatment and prognosis, one must 
divide the spine into sections. 




The divisions of the spine. 



Divisions of the Spine. 

1. The neck part, that allows free motion of the head, ending at 
the third dorsal vertebra. 



DIVISIONS OF THE SPINE. 



31 



2. The rigid thoracic part which includes the third and the tenth 

dorsal segments. 

Fig. 9. 




4 <p !uO(jjrf 
imp Piwueyj; 



Cross-section of the body of a child at the third dorsal vertebra. (Dwight.) 

3. The lower portion made up of the two lower dorsal and the 
lumbar vertebrae, in which the principal movements of the trunk are 
carried out. One must bear in mind the distribution of the nerves, 
because the characteristic pain is referred to their terminations, also 



32 TUBERCULOUS DISEASE OF THE SPINE. 

the parts in relation to the spine at different levels, that may be im- 
plicated in the disease. Thus, remembering that the symptoms of 
Pott's disease are in general stiffness, weakness, pain and deformity, 
one will always apply these symptoms to a particular region of the 
spine, and will picture to himself the effect of such stiffness, weakness 
and deformity at this or that vertebra ; the effect of an abscess in this 
or that situation, and the area of paralysis that might be caused by 
pressure on the cord at one or another level. 

Landmarks. — The atlas is on a line with the hard palate. 

The axis is on a line with the free edge of the upper teeth. 

The transverse process of the atlas is just below and in front of the 
tip of the mastoid process. 

The hyoid bone is opposite the fourth cervical vertebra. 

The cricoid cartilage is on a line with the sixth cervical vertebra. 

The upper margin of the sternum is opposite the disc between the 
second and third dorsal vertebrae. 

The junction of the first and second sections of the sternum is op- 
posite the fourth dorsal vertebra. 

The tip of the ensiform cartilage is opposite the lower part of the 
body of the tenth dorsal vertebra. 

The anterior extremity of the first rib is on a line with the fourth 
rib at the spine, the second with the sixth, the fifth with the ninth, 
the seventh with the eleventh. 

The scapula overlaps the second and the seventh ribs, its lower angle 
being opposite the center of the eighth dorsal vertebra. 

The root of the spine of the scapula, the glenoid cavity, and the inter- 
val between the second and third dorsal spines are in the same plane. 

The most constant landmark from which to count, is the spinous proc- 
ess of the fourth lumbar vertebra, which is on a line with the highest 
point of the crest of the ilium. The umbilicus is near the same plane. 

The Inclination of the Pelvis. — In the erect attitude the plane of the 
brim forms an angle of 60 to 65 degrees with the horizon. 

The tip of the coccyx is opposite the lower, border of the symphysis 
pubis. 

Length of the Spinal Cord. — In the adult the spinal cord terminates 
at the lower margin of the first lumbar vertebra. At birth, it extends 
to the third lumbar and its membranes to the second division of the 
sacrum. 

The Intervertebral Discs. — In the adult, the intervertebral discs 
form 41.9 per cent, of the cervical, 26.4 per cent, of the dorsal, and 
44.6 per cent, of the lumbar regions of the spine (D wight). 

The Rational Signs. 

The symptoms of Pott\s disease vary decidedly, not only with the 
region of the spine involved, but also with the age and surroundings 
of the patient. Like other forms of tuberculous disease it is an insidi- 
ous chronic affection and its early symptoms may fail to attract atten- 



HISTORY. 33 

tion, because they are irregular or intermittent. The child may cry 
after over-exertion or injury, but afterward it may appear to be in its 
usual health, perhaps for days or weeks ; but even during this early 
stage, it will be remembered afterwards, that something was " wrong," 
that it was fretful and disinclined to play, that it liked to lie on the 
floor, that it was awkward in its movements, that it was troubled by a 
cough or indigestion, or by oppression of breathing. One, or many, 
of such symptoms may have existed for months, but, as a rule, it is 
not until deformity has made the diagnosis unmistakable, that the 
child is brought for treatment. It is often after a fall or violent play, 
that the evidence of pain or weakness can no longer be overlooked, so 
that injury is likely to occupy a prominent place in the history. 

History. — The history of the disease as obtained from the parent is 
usually indefinite and misleading. Certain points may however be set 
down as of relative importance. 

One will ask if the immediate relatives of the child have suffered 
from phthisis or other form of tuberculosis, as this might indicate a 
predisposition to disease, and thus affect the prognosis. 

One asks if the child has been robust or the reverse ; if recovery 
from the ordinary ailments of childhood was prompt or tedious, in 
order that one may judge of the quality of the patient. 

One next asks, not " how long has the child been ill ? " for this is 
usually understood to refer to the duration of the more decided symp- 
toms, but " when was the child last perfectly well ? " One asks par- 
ticularly as to the onset of the first symptoms, whether it was sharp 
and decided, or gradual and ill defined ; if the symptoms were preceded 
by contagious disease. This latter is an important question, because 
measles, for example, predisposes to tuberculous infection or at least 
to its local outbreak, and diphtheria is often followed by paralysis or 
by weakness, that may simulate certain symptoms of Pott's disease. 
The character of the injury, that almost every patient is supposed to 
have received, is then investigated. It should be made clear, whether 
the injury was the direct cause of the symptoms or if it may have 
simply aggravated, or brought to light the dormant disease or if, as is 
often the case, there is simply an indefinite remembrance of an injury 
which has no connection with the symptoms. 

To establish injury as the sole and direct cause of symptoms, the 
patient must have been well at the time of the accident, the symp- 
toms must have followed immediately and have continued since ; 
and finally the symptoms must be of such a nature as to be explained by 
a definite injury. 

By careful questioning one may usually determine whether the 
symptoms of which the patient complains are acute or chronic. This 
is of importance because tuberculosis is a chronic disease, one of the 
few chronic diseases of childhood, although its exacerbations may re- 
semble, in symptoms, those of acute disease or even of injury. 

However important a correct history may be, the actual diagnosis 
depends entirely upon the physical examination. 
3 



34 TUBERCULOUS DISEASE OF THE SPINE. 

Physical Signs. 

The physical examination begins on the first sight of the patient, 
when one notes the general condition and the actions and postures ; 
but the ultimate purpose is to compare the appearance and mobility of 
the spine suspected of disease, with the normal standard. 

Voluntary actions and attitudes show the adaptation of the body to 
the disease, the conscious and unconscious efforts of the patient to 
guard the weak part from strain, and from motions that cause discom- 
fort and pain. But by inspection, palpation, and by the tests of 
voluntary and passive motion, one may demonstrate and localize the 
disease. 

The examination must be purposeful. When one asks the patient 
to pick up a coin from the floor — the popular test for Pott's disease — 
one employs it to test the mobility of the lower region of the spine, 
the region in which the motions of stooping and turning the body are 
carried out ; remembering that such movements are often not restrained 
in the slightest degree by disease in the upper portion of the spine. 

Such tests must not only be purposeful, but they must be adapted 
to the age and intelligence of the patient. The child that refuses to 
pick up a coin will often gather up its clothing, because it wishes to 
be dressed again. If it will not stoop, it will usually rise if placed in 
the recumbent or sitting posture, which is an equally useful test. A 
child will walk towards its mother, if placed at a distance from her. 
It will always turn its head towards her, thus voluntary motion of 
the cervical region may be tested by changing the mother's position, 
while the child is held by the examiner. Young children, who strug- 
gle and resist passive motion if placed on the table, submit quietly 
when held in the mother's arms. 

Various simple and effective tests will suggest themselves to the ex- 
aminer, who has a definite purpose in view, but much patience may be 
required in early cases and several examinations may be necessary be- 
fore the presence or absence of disease can be definitely determined. 
It is important to remember that in childhood at least, abnormal 
symptoms always have a cause, therefore a patient should always be 
kept under observation until the cause is finally discovered. 

Of all the early signs of Pott's disease muscular rigidity or reflex 
muscular spasm is the most important, since it precedes deformity and 
accompanies it, until cure is finally established. It is a spasm that 
resists motion in all directions ; thus it may be distinguished from 
the spasm or contraction of certain groups of muscles resulting from 
irritation or inflammation not connected with the spine. For in such 
instances motion is limited only in the directions directly opposed by 
the muscular contraction. True reflex muscular spasm is quite inde- 
pendent of the will, and thus it may be easily distinguished from sim- 
ple voluntary resistance on the part of the patient. 

The muscular rigidity is most marked in the neighborhood of the 
disease, but it extends to a greater or less distance according to the 



THE REGIONAL EXAMINATION. 35 

acuteness of the local process and the susceptibility of the patient. 
Even at an early stage the situation of the disease is usually shown by 
a slight irregularity of the spine in the center of the area, made rigid 
by muscular spasm, as well as by the change of contour. This change 
in outline and in flexibility may be demonstrated by bending the 
patient forward. If the spine forms a long, even, regular curve and 
if there be no evidence of pain or rigidity, when such an attitude is 
assumed, Pott's disease is extremely improbable. If, on the other hand, 
the outline of the curve is broken ; if the motion of one section of the 
spine is restrained by muscular rigidity, disease may be suspected, and 
if other evidence of tuberculous ostitis is present, the diagnosis may be 
made with certainty. (Figs. 6 and 7.) 

By a careful physical examination one may expect to detect Pott's 
disease at any stage and to fix upon its location, or at least upon the 
point suspected of disease. One Avill then ask oneself if tuberculous 
disease of the bodies of the vertebrae of this particular region will 
satisfactorily explain all the symptoms of which the patient complains ; 
if for example, the pain corresponds to the distribution of the nerves, 
if restraint of function will explain the attitudes of the patient, if the 
change in contour is significant of a destructive process, and the like. 

The principles of differential diagnosis having been outlined they 
may be applied to the detection of disease as it appears in the different 
regions of the spine. 

The Regional Examination. 

1. The Lower Region. — Considering the regions of the spine in 
the order of liability to disease one begins with the lower section com- 
prising the lumbar and the two lower dorsal vertebrae, that more nearly 
correspond in shape and function to the lumbar than to the thoracic 
division. 

This is the region of constant and extensive motion, thus the pain- 
ful rigidity, characteristic of the disease, is often marked long 'before 
the stage of bone destruction. 

The characteristic attitude of the patient is one of what might be 
called over-erectness and often there is an increased hollowness (lordosis) 
(Figs. 10 and 12) of the back, so that the prominent abdomen may first 
attract attention. The walk is careful, and a peculiar tip-toeing step 
with slight inversion of the feet to avoid the jar of striking the heels 
is often observed ; this is however not a peculiarity of disease of this re- 
gion alone, but is rather an evidence that the spine is sensitive to slight 
jars. More characteristic of lumbar disease is a peculiar icaddle, ex- 
plained in part by the exaggerated lordosis, and in part by the loss of 
the accommodative, balancing motion of the lumbar spine, as the weight 
falls alternately on each leg in walking. 

The increased lumbar lordosis, so characteristic of the early stage of 
the disease, is capable of several explanations. It is partly voluntary ; 
as bending the body forward brings pressure upon the diseased verte- 
bral body, so bending it backward relieves this pressure. It is partly 



36 



TUBERCULOUS DISEASE OF THE SPINE. 



involuntary, caused by the contraction of the large muscular masses 
on the posterior aspect of the spine ; and it is in part compensatory, 
as the slight psoas contraction which is often present has a tendency 
to tilt the pelvis forward, necessitating a greater compensatory back- 
ward inclination of the body. 

As the disease progresses, the lumbar section becomes straighter, 
aud finally it may project backward in the characteristic angular de- 
formity. Yet even after the lordosis has been obliterated the back- 



Fig. 10. 



Fig. 11. 




Disease of the upper lumbar region before 
the stage of deformity, showiDg abnormal 
lordosis. 




The same patient (Fig. 10) five years 
later showing deformity. 



ward inclination of the body still continues as a compensation for the 
change in balance, which the transformation of the forward curve to a 
posterior deformity has necessitated. (Fig. 11.) Thus over-erectness 
or backward inclination of the body characterizes the disease of this 
region from its beginning to its end in uncomplicated cases. 

Slight psoas contraction as a part of the general muscular spasm 
about the point of disease, simply increases the lordosis, but if the 
contraction is greater, when, for example, an abscess is present which 
involves the substance of the psoas muscles or forms a painful tumor 



THE REGIONAL EXAMINATION. 



37 



in the pelvis, the erect attitude is no longer possible. The legs are 
drawn toward the body, and the body is inclined forward, to relax 
the tension. This greater contraction, with the abscess that is usually 
its cause, is most often limited to one side ; thus the patient inclines 
the body somewhat forward and toward the flexed leg, " favors it " 
and the resulting limp is usually mistaken for a sign of hip disease. 

Fig. 13. 



Fig. 12. 





Disease of the lumbar region. First 
symptom, pain in the knees. 



Disease of lumbar region with right ilio-psoas abscess 
and psoas contraction. 



Unilateral psoas contraction is, in fact, so often present when the pa- 
tient is first brought for treatment, that a limp and the accompany- 
ing inclination of the body may be considered as characteristic of dis- 
ease of the lumbar region at a somewhat later stage. 

The location of the pain depends upon the distribution of the nerves 
that supply the diseased vertebrae or that pass in its vicinity ; it may 
radiate over the inguinal region or backward to the loins or buttocks 



38 



TUBERCULOUS DISEASE OF THE SPINE. 



Fig. 14. 



or down the front or back of the legs to the knees. Painful cramp in 
the leg is sometimes a symptom ; the thigh is spasmodically drawn 
toward the body and the patient, seizing it with both hands, shrieks 
with pain. 

Lateral inclination of the body is often present. It is usually a 
symptom of unilateral psoas contraction and abscess ; it may be due 
also to unilateral contraction of the muscles of the back, or at a later 
stage, it may indicate collapse or destruction of one side of a vertebral 
body. In other instances it is not a fixed attitude, but is simply a 
voluntary adaptation to weakness or pain ; thus one may find a large 
abscess in one pelvic fossa unaccompanied by psoas contraction, while 
the body is inclined toward the opposite side, the weight being borne 

habitually on that leg. 

The stiffness, weakness and pain, char- 
acteristic of disease in this region are 
exemplified in many ways, for example, 
the child may be unable to turn in bed ; 
it is slow and awkward in rising in the 
morning or in changing from an attitude 
of rest to one of activity. It often pre- 
fers to stand rather than to sit because 
in the latter position more weight is 
thrown upon the sensitive vertebral 
bodies. When seated, particularly when 
riding in a carriage or street car, the 
patient often sits upon the edge of the 
seat, the shoulders only touching the 
back, while the hands rest instinctively 
on the seat, partially supporting the 
weight and steadying the spine. 

Stooping, a posture that increases the 
pressure on the diseased vertebral bodies 
and which necessitates muscular tension 
and strain in regaining the erect posi- 
tion, is particularly difficult and it is 
always avoided by the patient if the 
disease is at all acute. For example when the child is asked to pick 
up an object from the floor, it either refuses, or it squats on the heels 
or drops upon the knees (Fig. 14) instead of flexing the spine as in 
health. Young children, having seized the object on the floor, regain 
the erect attitude by pushing the body up by the pressure of the hands 
on the thighs. If the child is placed upon the floor it will, if possible, 
seize the mother's dress or will crawl to a chair or other object upon 
which the body may be drawn up by the arms so that the discomfort 
caused by muscular contraction of the back muscles may be avoided. 

After the inspection, and the observation of the motions and atti- 
tudes of the patient, the examination of the range of passive motion 
is made. The patient is placed at full length face downward on a 




Lumbar disease. The manner of pick- 
ing up an object. 



THE REGIONAL EXAMINATION. 



39 



table, and the range of extension, and of lateral motion is tested by 
lifting the legs and swaying the body gently from side to side. (Fig. 



Fig. 15. 




Showing the rigidity of the spine before appearance of deformity. 

15.) The spine is so flexible in childhood, that rigidity even in the 
upper dorsal region may be demonstrated by this method, and in test- 

Fig. 16. 




Test for psoas contraction. 



ing the lumbar region, the thorax should be fixed by the hand of the 
examiner. While the patient remains in this attitude, one should tes t 



40 



TUBERCULOUS DISEASE OF THE SPINE. 



for psoas contraction ; the pelvis is pressed firmly against the table 
with one hand, while the leg, held in the line of the body, is gently 
lifted by the other. (Fig. 16.) As tested in this manner, the 
normal range of extension should allow the knee to be lifted two or 
three inches from the table. Slight restriction of extension of both 
thighs, indicating a slight degree of psoas contraction, is very common 
in lumbar Pott's disease, but when the restriction is marked, and es- 
pecially if it be unilateral, a deep abscess may be suspected. Such 
unilateral psoas contraction may be more clearly demonstrated by 
placing the child on the back, allowing the legs to hang over the edge 
of the table, when the unaffected thigh will drop below its fellow. 
(Fig. 17.) 

As a rule, flexion of the lumbar spine is much more restricted in 
the early stage of the disease than is extension ; this rigidity and fixa- 

Fig. 17. 




A method of demonstrating psoas contraction. 



tion may be demonstrated by placing the child on its hands and knees, 
and lifting it from the floor ; when the body, instead of bending over 
the supporting hands, retains almost its original contour. (Fig. 18.) 

As has been stated, even at an early stage of the disease one may 
often detect a slight fullness about the spinous processes or a slight 
irregularity in their line, about which the muscular spasm is most 
marked ; this indicates the exact seat of the disease. Deep pressure 
on the spinous processes at this point will often cause pain, and some- 
times greater elasticity at the diseased area may be demonstrated. 
Except in the hands of an expert, it is, however, a test of compara- 
tively little value ; and it may be again mentioned that local pain and 
local sensitiveness to pressure on the spinous processes, are not char- 
acteristic signs of Pott's disease. 

Finally, one should always examine for pelvic abscess. This may 



DIAGNOSIS. 



41 



be suspected when unilateral psoas contraction is present in marked 
degree, although psoas contraction may be present without abscess and 
abscess may be unaccompanied by psoas contraction when the sub- 
stance of the muscle is not involved. 

The typical psoas abscess, as pictured and described, is the fluctu- 
ating tumor, that suddenly appears on the inner side of the thigh, 
although it may have been many months in descending to this position 
from its original site. Demonstrable abscess is present at some time, 
in at least 50 per cent, of the cases of lumbar disease, and its early 
detection is a matter of importance, since its subsequent behavior will 

Fig. 18. 




Disease of the lumbar region before the stage of deformity. A test for rigidity. 



often materially influence the treatment. The child is placed on the 
side, the thigh is flexed and the hand is pressed gently down into the 
loin and iliac fossa. Sometimes the examination will be made easier 
by extending the leg and thus bending the spine forward toward the 
hand. Often, in this manner, one can make out the peculiar sausage- 
like thickening on one or the other side of the spine, or a larger 
rounded tumor in the iliac fossa, the presence of which w T ould not 
otherwise have been suspected. 

Diagnosis. — If a careful physical examination were made in all 
suspicious cases, by one at all familiar with the ordinary symptoms of 



42 TUBERCULOUS DISEASE OF THE SPINE. 

Pott's disease, the field for differential diagnosis would be small in- 
deed ; but it would appear that such examinations are not often made 
by the physician who is first consulted. One is often told that the 
child has been circumcised because of pain about the genitals, or be- 
cause of weakness of the limbs, supposed to be due to " reflex irrita- 
tion "; or if the patient be an adult, that he has been treated for 
sciatica, rheumatism or strain, long after the evidence of Pott's dis- 
ease, even in the angular kyphosis, would have been apparent on 
examination. 

Pott's disease is most often mistaken for some one of the following 
affections. 

Lumbago — may simulate some of the symptoms of Pott's disease 
of this region, but it is an acute affection, of sudden onset, usually 
accompanied by local pain and tenderness of the muscles themselves. 

Strain of the Back — is often accompanied by stiffness and pain on 
motion, but like lumbago, its onset is sudden and its cause is known. 
The pain is usually localized at the point of injury, it is relieved by 
rest, and the restriction of motion is, in great degree, voluntary. In 
Pott's disease the pain is neuralgic ; it is often worse at night and 
the rigidity is due to reflex spasm. 

Sciatica. — The pain of sciatica is most often unilateral ; it is usually 
confined to the distributions of this nerve which is often sensitive to 
pressure throughout its course. The pain of Pott's disease, if it is re- 
ferred to the legs, is usually bilateral and the nerve trunks are not 
often sensitive to pressure. In sciatica, movements of the leg that 
cause tension on the nerve, are often painful, while motion of the spine 
is free, or but slightly restricted, the reverse of the symptoms of Pott's 
disease. It is true that lateral deviation and even rigidity of the lum- 
bar spine are sometimes observed in cases of sciatica of long stand- 
ing, but if the latter symptom is marked, the diagnosis may be re- 
garded as open to question. Sacro-iliac disease is far more likely to 
be mistaken for disease of the hip than of the spine ; the pain and 
sensitiveness are usually localized about the seat of disease and the 
motions of the spine are not restricted. 

Lumbago and sciatica and sacro-iliac disease are extremely uncom- 
mon in childhood, and if supposed strains or injuries of the back cause 
persistent symptoms, the appropriate treatment would be similar to that 
of Pott's disease ; that is to say, fixation and rest of the suspected part, 
until the cause of the symptoms is made clear. 

The attitude, characteristic of Pott's disease of this region, the 
hollow back, the prominent abdomen combined with the waddling 
gait, may be simulated by Bilateral Congenital Dislocation of the Hip, 
in which the pelvis is suspended at a point behind its normal position, 
but in this deformity the gait and attitude have existed since the child 
began to walk, and are accompanied by the symptoms of bone disease. 
A similar attitude is sometimes the result of weakness or paralysis of 
the muscles of the back, as for example in Progressive Muscular Atro- 
phy, and again in Pseudo-hypertrophic Muscular Paralysis. In this 



DIA GNOSIS. 



43 



latter affection there is also a disinclination to stoop, and there may be 
rigidity of the back, symptoms that, in the early stages, bear a super- 
ficial resemblance to Pott's disease, but as there are no other signs of 
disease of the spine, it can be readily excluded. 

When psoas contraction is present in lumbar Pott's disease, the re- 
sulting limp, that is often accompanied by pain in the leg, is almost 
invariably mistaken for a symptom of Hip Disease. 

It will be remembered that although flexion of the leg caused by 
psoas contraction is a common 

symptom of Pott's disease, it is Fig. 19. 

as a rule not an early symp- 
tom; thus the history will prob- 
ably call attention to symptoms 
referable to the back that have 
preceded it. Again, the limp of 
Pott's disease is caused simply 
by flexion of the leg, a limp that 
is not, as in joint disease, ac- 
companied by pain on functional 
use. When therefore, in the 
physical examination, the ten- 
sion of the contracted ilio-psoas 
muscle is relieved by flexing the 
thigh still further, the other 
movements of the hip, flexion, 
rotation and the like, may be 
shown to be free and unre- 
strained. Thus hip disease, in 
which all motions are restrained 
in equal degree by muscular 
spasm, may be easily excluded, 
except perhaps in infancy. 

Hip Disease in Infancy. — At 
this susceptible age there is 
almost always a sympathetic 
spasm of the lumbar muscles in 
acute affections of the hip, and 
similar spasm of the hip muscles 
in disease of the lower part of 
the spine ; so that several ex- 
aminations may be necessary 
before an exact diagnosis can be 
made. In such cases the application of a temporary support to the 
back and leg, such as a spica plaster bandage which will relieve the 
secondary spasm, is a useful aid in diagnosis. 

It has been stated that extension of the thigh is alone restrained in 
psoas contraction ; it will be evident, however, that the presence of a 
large and painful abscess in the pelvis or thigh would limit motion in 




Disease of the lower dorsal region. The earliest 
indication of deformity. 



44 TUBERCULOUS DISEASE OF THE SPINE. 

other directions as well ; but even in such cases, motion in one or more 
directions usually remains unrestricted ; thus disease within the joint 
may be excluded. 

Secondary Hip Disease. — In Pott's disease of long standing compli- 
cated by abscess in which the tissues about the joint are infiltrated, or 
traversed by discharging sinuses, secondary infection of the hip joint 
is not an unusual complication. In such cases it is not always easy to 
decide whether it is or is not present, when the limb is distorted and 
when motion at the hip is limited by the infiltrated and contracted 
tissues in its neighborhood. 

Pelvic Abscess. — As abscess is such a common complication of Pott's 
disease, it will be necessary to consider abscesses of other origin, that 
may occasionally cause symptoms resembling somewhat those of dis- 
ease of the spine. Such are the perinephritic abscess, and more rarely, 
that of appendicitis. They differ from the abscesses of Pott's disease in 
that they are, as a rule, acute in their onset and are accompanied by 
constitutional symptoms and by local pain and tenderness. In such cases 
the motions of the spine may be restrained, but the restraint is in great 
degree voluntary, quite different from the rigidity due to disease of its 
substance. It is true that the pelvic abscess of Pott's disease which 
has become infected may cause constitutional symptoms, but the history 
of the disability and discomfort that must have preceded the abscess, 
together with the probable presence of deformity, will make the diag- 
nosis clear. Chronic abscess in the pelvis of other than spinal origin, 
may be the result of disease of the pelvic bones, or of the sacro-iliac 
articulations, or of the hip joint. It may be caused by the breaking 
down of lymphatic glands, or it may have its origin in inflammation 
about the uterine appendages ; and cases of so-called idiopathic in- 
flammation and suppuration of the ilio-psoas muscle have been de- 
scribed. In childhood, chronic abscesses in this locality are almost 
always tuberculous in character, and are caused by disease of bone, 
either of the spine or of the pelvis. Disease of the spine can be deter- 
mined usually by the methods already indicated, but if the abscess is of 
other origin, its exact cause can be decided in many instances only by 
an operative exploration. Abscesses of this character, of slow and 
apparently painless formation may finally cause a swelling in the 
inguinal region or about the saphenous opening, that in the adult is 
not infrequently mistaken for hernia. In practically all cases, how- 
ever, the tumor of the abscess may be made out on palpation within 
the pelvis, while the swelling, although its contents may be in part 
forced into the abdominal cavity, is very different in feeling from the 
complete reduction that is usually possible in the ordinary hernia. In 
addition some sign of the disease of the spine or pelvis, of which the 
abscess is a result, is almost always present. 

Peculiarities of Lumbar Pott's Disease in Infancy. 

Attention has been called repeatedly to the great importance of the 
careful observation of the postures and movements of the patient, to 



PECULIARITIES OF LUMBAR POTTS DISEASE IN CHILDREN. 45 

the change in the contour of the spine and particularly to the abnormal 
lordosis and peculiar attitude of over-erectness in the early stage of 
lumbar disease. But the description of attitudes of standing and 
walking, and the shape of the spine which is the result of the erect 
posture does not apply to the infant in arms, nor need the spine be 
divided into contrasting sections for the purpose of differential diag- 
nosis. In Pott's disease of infancy the muscular spasm is more intense 
and its extent is greater. The child screams when it is moved or 
when the diapers are changed. There is usually no difficulty in de- 
termining the presence of disease from the evidence of rigidity and 
pain, but, as has been mentioned, it is sometimes difficult to decide 
whether the lumbar spine or one of the hip joints is involved. Slight 
irregularity of the spinous processes indicating the position of the de- 
structive process is often evident at an early stage and early abscess is 
not unusual. 

Pott's disease of infancy might be mistaken for acute ?*hachitis or 
scurvy but for the fact that the symptoms of such affections are not 
limited to the spine but involve to a greater or less degree the limbs 
and joints, the enlarged epiphyses and other evidences of rhachitis show- 
ing that the discomfort and pain are due to a general, not to a local disease. 

The Rhachitic Spine. — The deformity of the spine, caused by rhachitis 
is not infrequently mistaken for the kyphosis of Pott's disease. 

It has been stated that a long posterior curvature of the spine char- 
acterized the weakness of infancy. It is also characteristic of other 
forms of weakness and particularly that caused by rhachitis in early 
childhood. During the subacute stage of general rhachitis the child 
that has never walked or that has " lost its walk " sits much of the 
time in its chair, or is held in this position on the mother's arm so 
that the spine is bent backward and a curvature of the lower thoracic 
and lumbar region is habitual. Soon a slight projection persists, even 
when the child is lying down ; it usually increases in size and becomes 
more rigid and permanent, if its exciting cause remains ; thus a some- 
what rounded and rigid posterior curvature of the dorso-lumbar por- 
tion of the spine is formed. 

The diagnosis from Pott's disease should be made without difficulty, 
because the evidence of general rhachitis is always present so that such 
deformity is almost as much to be expected as would be distortions of 
the legs were the child walking. If the patient is placed in its habit- 
ual sitting posture it will be seen that the deformity is simply an ex- 
aggeration of a normal attitude. In this attitude the patient remains 
contentedly for an indefinite time, whereas if Pott's disease were 
present, the child would lie on its back or abdomen. Finally, the 
projection is rounded, not angular, and if the patient be placed in the 
prone posture the projection may be reduced, in great part, by raising 
the thighs while gentle pressure is exerted upon the kyphosis ; and 
although the spine is somewhat rigid, and although such extension and 
pressure may be resisted by the patient, yet there is complete absence 
of the muscular spasm characteristic of Pott's disease. 



46 TUBERCULOUS DISEASE OF THE SPINE. 

It may be stated then that the rhachitic deformity is a rounded 
curvature of the lower part of the spine. Its cause is weakness and 
habitual posture. The rigidity depends upon the duration of the de- 
formity. The pain, if the rhachitis be acute, is general and is easily 
explained by the sensitive condition of the bones and joints. It is 
true that rhachitis and tuberculous disease of the spine may be com- 
bined, but in such rare instances the symptoms of the more serious 
local disease will make themselves evident as distinct from those of 
the general weakness. 

Recapitulation. — The more characteristic symptoms of disease of 
the dorso-lumbar region may be summed up as follows : 

Increased lordosis or over-erectness and a prominent abdomen ; a 
cautious, constrained or waddling gait ; less often, a lateral inclination 
of the body, or a limp caused by psoas contraction. 

Stiffness of the spine, which makes bending or turning the body 
difficult. 

Pain, referred to the back, the inguinal region or down the legs, and 
in more advanced cases, the characteristic deformity. 

Diagnosis. — The attitude may be simulated by congenital disloca- 
tion of the hips and by pseudo-hypertrophic muscular paralysis or, more 
rarely, by progressive muscular atrophy. 

The limp may be mistaken for that of hip disease. 

The pain and stiffness for sciatica, rheumatism, lumbago or injury. 

The abscess is to be distinguished from those from other sources. 

In young infants the symptoms may be simulated by hip disease 
and by acute rhachitis. 

Finally the deformity of the subacute form of rhachitis is to be dis- 
tinguished from that symptomatic of bone destruction. 

Disease of the Middle or Thoracic Region of the Spine. 

The normal motion of this section of the spine, which includes the 
third and tenth vertebrae is, as compared with those above and below 
it, slight ; thus, disease of this region may not interfere to a notice- 
able degree with the general function of the spine. 

As this part of the column curves backward, the deformity, often 
unattended by severe symptoms, is not infrequently mistaken for 
round shoulders. It seems probable also, because of the normal back- 
ward curve, and because of the leverage exerted by the weight of the 
head and arms, that deformity quickly follows disease. At all 
events, patients are not often seen before it is present, so that diag- 
nosis is usually evident on inspection of the patient. 

The attitudes are not especially significant. If the lower part of 
this region is involved, and if the disease be at all acute, they are 
similar to those of disease of the lower region, viz.: erectness, the 
peculiar, cautious, in-toeing step, and the disinclination to bend the 
body forward. 

If, on the other hand, the upper part is affected, the attitude is 



DISEASES OF MIDDLE OR THORACIC REGION OF SPINE. 



47 



often, particularly in young children, one of weakness ; there is a 
slight forward inclination of the body while the head is tilted back- 
ward or is inclined toward one side. A peculiar shrugging, squareness 
and elevation of the shoulders is often noticed. (Fig. 21.) In many 
instances the apparent elevation of the shoulders is in reality caused 
by the deformity, which shortens the neck and lowers the head. 

In this connection, it should be mentioned that one of the secondary 



Fig. 21. 



Fig. 20. 





Pott's disease of the middle dorsal region at 
an early stage, showing slight increase of the 
dorsal kyphosis. 



Disease of the upper dorsal region. 
Characteristic attitude. 



effects of the disease, the so-called pigeon breast, is, not infrequently, 
noticed by the parent before the angular deformity of the spine. In 
the pigeon breast of Pott's disease, the forward inclination of the spine 
causes a flattening of the upper part of the chest, while the sternum 
sinks downward and becomes prominent, thus the antero-posterior 
diameter of the chest is increased, and it is compressed from side to 
side, so that it resembles very closely the deformity of rhachitis. As 



48 



TUBERCULOUS DISEASE OF THE SPINE. 



Fig. 22. 



the pigeon breast of Pott's disease is always secondary to the deformity, 
its cause, of course, becomes apparent on examining the spine. 

Of the early symptoms of dorsal disease, pain and labored or 
" grunting " respiration are the most characteristic. Pain referred to 
the abdomen and to the front and sides of the chest is usually an early 
and often a constant symptom : thus persistent " stomach-ache " in a 
child should always lead one to an examination of the spine. A 

" spasm of pain " is sometimes excited by 
lateral compression of the chest, as when 
the child is lifted suddenly by the parent. 
Of much greater importance, however, 
is the labored or grunting respiration, which 
indeed is almost pathognomonic of Pott's 
disease. This " grunting " is caused by 
the interference with respiration, more par- 
ticularly with the normal rhythmical move- 
ments of the ribs. The restraint is, in part, 
due to muscular spasm, and in part to the 
voluntary efforts of the patient. The in- 
spiration is quick and shallow, in great 
degree diaphragmatic, and expiration is 
accompanied by a sigh or grunt. This is 
apparently caused by a momentary closure 
of the larynx to resist the escape of air and 
thus sudden motion of the chest wall. 
Grunting respiration is, of course, an evi- 
dence of the more acute type of disease, but 
even in mild cases in children it will be 
noticed when the patient is fatigued, or 
during play. 

An irritating, aimless cough is often a 
symptom of disease of the upper dorsal 
region, and spasmodic attacks resembling 
asthma are not uncommon. 

The physical examination will, in most 
cases, show the characteristic angular ky- 
phosis, and in the exceptional cases, in 
which deformity is absent, a slight change 
in contour w T ill be apparent when the pa- 
tient is bent forward. In place of the long 
regular curve of the normal spine, a point 
where two distinct outlines unite will be observed, one of which may 
be curved while the other is practically straight. 

The presence of muscular spasm may be shown by sudden move- 
ment of the spine, and it may also be demonstrated, in children, by 
raising the legs and swaying the body from side to side, as illustrated 
in the preceding section. (Fig. 15.) The change in the rhythm of 
respiration has already been mentioned ; the restraint does not affect 




Marked lateral deviation of the 
spine with rotation. Deformity at 
the eighth dorsal vertebra. 



DISEASE OF MIDDLE OR THORACIC REGION OF SPINE. 



49 



the motion of all the ribs equally, those that articulate with the diseased 
vertebrae are often nearly motionless while the movement of those at a 
distance may approach the normal. 

In tracing the neuralgic pain to its origin, the sharp downward in- 
clination of the ribs must be borne in mind ; thus, the cause of pain 
in the " stomach " must be looked for between the shoulder blades. 

As in the lumbar region, slight lateral deviation of the spine is not 
uncommon, and it may be accompanied by a slight twist or rotation so 
that the ribs on one side are more prominent. (Fig. 22.) 

Fig. 23. 




Double psoas 



contraction of an extreme degree and paralysis. The arms used as supports. 



In disease of this region of the spine the spinal cord is more often 
involved than elsewhere, thus an awkward stumbling gait and finally 
a " loss of walk " may be the symptoms that first attract attention. 
This paralysis of Pott's disease and its differential diagnosis are con- 
sidered elsewhere. 

Abscess as a complication, can not be demonstrated by palpation 

unless it has found an outlet between the ribs, but percussion will 

often show an area of dullness or flatness, extending from the diseased 

vertebrae toward the lateral aspect of the chest, due in part, however, 

4 



50 TUBERCULOUS DISEASE OF THE SPINE. 

to the inflammatory thickening of the tissues in the neighborhood. 
In rare instances the abscess may press directly upon the trachea or 
bronchi and cause spasmodic attacks of dyspnoea resembling asthma. 

Diagnosis. — It is hardly necessary to mention the list of affections 
that may cause pain in the chest or abdomen ; it is sufficient to state 
that such symptoms always require a physical examination. The same 
statement applies to irregular respiration, to cough and so-called asthma. 

Occasionally tuberculous disease of the dorsal spine in adolescence, 
is not only practically painless, but the resulting deformity is rather 
rounded than angular, so that it may be mistaken for round shoulders. 
" Eound shouldees " is however, as a rule, of longer duration ; some 
exciting cause of postural deformity, in occupation or otherwise, is 
usually apparent ; while the rigidity is less marked than in Pott's dis- 
ease and pain is absent. 

The situation and shape of the rhachitic kyphosis has been de- 
scribed. It should be evident, that a more or less angular projection, 
in the upper part of the spine could not be rhachitic, and yet because 
of the absence of pain, this diagnosis is not infrequently made, and as 
a consequence, the activity of the tuberculous disease may be increased 
by massage and exercises. 

Lateral deviation of the spine as a symptom of disease, could not 
be mistaken for the ordinary rotary-lateral curvature, in which pain and 
muscular rigidity are absent. 

Acute affections within the chest, pleurisy, pneumonia and empyema 
are sometimes accompanied by lateral deviation of the spine, but the 
sudden onset, and the constitutional and local symptoms that accom- 
pany such affections should make the cause of the deformity and pain 
evident. It is because these cases are sometimes sent to orthopaedic 
clinics for braces that such causes of deformity seem worthy of men- 
tion. 

The abscess of Pott's disease in this region, as has been mentioned, 
causes dullness or flatness on percussion of the chest and within this 
area friction sounds and rales may be heard. 

If the diagnosis of Pott's disease had not been made or if the pres- 
ence of the abscess had not been determined by the previous physical 
examination, it might be mistaken, during an acute exacerbation of 
the disease or constitutional disturbance from other cause, for pleurisy 
or empyema, and at other times for phthisis. The tuberculous fluid 
may remain indefinitely in the posterior mediastinum and the area of 
flatness may extend beyond the axillary line, yet it may give rise to 
no symptoms. 

In all cases then, a careful examination of the chest should be made 
from time to time in order that the presence or absence of abscess may 
be recorded. 

Recapitulation. — Pott's disease of this region is often insidious in 
its onset, causing no positive symptoms before the stage of deformity. 

Its most characteristic symptoms are pain referred to the front and 
sides of the body and the grunting respiration. 



THE UPPER REGION. 



51 



If the disease is progressive the ordinary symptoms of Pott's disease 
— weakness and rigidity — are present ; in the lower thoracic region, 
the attitude resembles that of lumbar disease ; in the upper, the head 
is usually tilted somewhat backward and the shoulders appear to be 
elevated. 

In differential diagnosis, one will consider the significance of pain, 
the cough or embarrassed respiration and the affections for which ab- 
scess or paralysis might be mistaken. 

Also round shoulders, rhachitic deformity and lateral deviation of 
the spine as distinguished from the kyphosis of Pott's disease. 

The Upper Region. 

The upper region of the spine, which includes the cervical and two 
of the dorsal vertebra?, corresponds in freedom of motion and in the 
forward curve, to the lumbar region. For the purpose of study, it 

Fig. 24. 




Cervical disease with abscess. Characteristic attitude. 



must be divided into two parts. Of these, the superior or occipito- 
axoid section is peculiar, in that it contains no vertebral body or inter- 
vertebral cartilage, and in that the movements of the head are carried 
out in special joints and are controlled by special muscles. 



52 TUBERCULOUS DISEASE OF THE SPINE. 

Disease at this point is especially dangerous, because displacement 
or fracture of the weakened vertebrae may cause sudden death by pres- 
sure on the vital centers. 

Occipito-axoid disease is comparatively rare, and it is relatively 
more frequent in adult life than in childhood. 

Symptoms. — In a typical case, the symptoms are neuralgic pain 
radiating over the back and sides of the head, following the distribu- 
tion of the auricular and occipital nerves. The neck is stiff and the 
head may be fixed in the median line, the chin being somewhat de- 
pressed, but it is more often tilted to one side, simulating the attitude 
of torticollis. (Fig. 24.) 

The attitude and appearance, when normal movement of the neck is 
cut off by a painful disease is characteristic ; the eyes follow one, or 
the body is turned, when the attention of the patient is attracted. The 
patient moves carefully, in order to avoid jar ; often the chin is instinc- 
tively supported by the hand, and a favorite attitude is one in which 
the patient sits with the elbows on a table, the hands supporting the 
head. (Fig. 25.) If the attempt is made to raise the chin, or to ro- 
tate the head, the patient seizes the hands of the examiner and, if a 
child, it screams in apprehension. There is often a slight bulging and 
thickening of the tissues at the seat of disease. The affected vertebrae 
are usually sensitive to deep pressure, and not infrequently, deep fluc- 
tuation in the sub-occipital triangle can be made out. 

The atlo-axoid junction lies just behind the posterior wall of the 
pharynx on a line with the upper teeth and here abscess often presents 
itself, occasionally early in the course of the disease, causing symptoms 
characteristic of obstruction, such as snoring, change in the quality of 
the voice, difficulty in swallowing, and sometimes spasmodic attacks of 
so-called croup. When abscess is present and when the disease is at 
all acute, the reclining posture sometimes aggravates the symptoms, so 
that " getting the child to bed " is often a tedious and difficult task. 

In certain cases, one may make out the exact location of the disease 
in the occipito-atloid or the atlo-axoid articulation, but as both joints 
are to a great extent controlled by the same muscles, this is often im- 
possible when muscular spasm is well marked. 

The uppermost joint, that between the atlas and occiput permits the 
nodding movement of the head, or flexion and extension on the spine ; 
while the atlo-axoid joint permits rotation of the atlas about the axis 
to the extent of about 30 degrees in either direction. If the disease 
be in the upper joint the nodding movements will be more restricted 
than those of rotation and vice versa. The motion of the entire cer- 
vical spine is very free so that to make the test one must grasp the 
neck firmly, in order to restrain motion except in the joint under ex- 
amination. Because of this freedom of movement, restriction of mo- 
tion, symptomatic of disease in the upper region, is often overlooked 
when it is of the sub-acute variety. 

The Lower Cervical Region. — The symptoms of disease of the lower 
cervical section, although similar in character, are often less marked 






SYMPTOMS. 53 

than those of the upper region. The cervical spine becomes straighter 
and often a slight backward projection or thickening indicates the posi- 
tion of the disease. The head is usually turned to one side by spasm 
of the lateral muscles in an attitude of wry neck. (Fig. 26.) The 
pain is referred to the neck, to the sternal region or down the arms, 
following the distribution of the brachial plexus. 

Fig. 25. 




Cervical disease. A characteristic attitude. 



In cases of more advanced disease, one's attention may be attracted 
to the cervical region, because the neck seems short and because the 
head is tilted backward. The entire back shows a compensatory flat- 
tening, yet no deformity is apparent until the occiput is raised and 
drawn forward, when a shelf-like projection may be felt, at what ap- 
pears to be the top of the spine, but which is really the angular de- 
formity at the third or fourth vertebra. 

This emphasizes the importance of a careful observation of the con- 
tour of the spine and the necessity of explaining to oneself every 
change from the normal that may be noticed. 

Disease at the cervico-dorsal junction resembles in its symptoms that 
of the upper dorsal region. The head is usually tilted backward (Fig. 
21) or it may be turned to one side. Disease at this point is often sub- 



54 



TUBERCULOUS DISEASE OF THE SPINE. 



Fig. 26. 



acute in character, and paralysis from implication of the spinal cord 
sometimes appears before deformity is apparent. 

The seventh cervical or first dorsal spine is often prominent (verte- 
bra prominens) in normal individuals and it may be mistaken for the 
deformity of disease, especially when pain about this point is a symp- 
tom, as in hysterical or hypersesthetic persons. If such projection is 
symptomatic of disease there is almost always a slight compensatory 
flattening of the spine below the point and a certain amount of rig- 
idity of the surrounding muscles. 

Diagnosis. — As stiffness and distortion of the neck are the most 

prominent symptoms of disease of this region it will be necessary to 

consider first, the forms of Torticollis for which it might be mistaken. 

In typical torticollis or wry neck, the distortion of the head is caused, 

almost invariably, by contraction of 
the muscles supplied by the spinal 
accessory nerve, the sterno-mastoid 
and trapezius, so that the chin is 
slightly elevated and turned away 
from the contracted muscle. 

Congenital Torticollis which has ex- 
isted from birth is not accompanied 
by pain and it could hardly be mis- 
taken for a symptom of disease. 

Acute rheumatic Torticollis, " stiff 
neck/' is sufficiently common to be 
familiar in its characteristics. It is 
of sudden onset, " in a single night"; 
the affected muscles are sensitive to 
pressure ; the course of the affection 
is short, and it is of comparative in- 
significance. 

A more persistent form of acute 
torticollis, accompanied by greater 
muscular spasm and by local tender- 
ness, sometimes follows of enlarged or suppurating cervical glands; it 
may follow " earache," tonsilitis or sore throat or any form of irritation 
about the pharynx. This form of wry neck is not only more painful, 
but it may last indefinitely, and permanent deformity may result. The 
onset is usually sudden ; the pain and tenderness are local, "and are 
confined, as a rule, to the contracted part. The sterno-mastoid and 
trapezius muscles are most often involved, thus the wry neck is typical. 
If the tension be relaxed by inclining the head toward the contracted 
muscle, motion of the spine itself will be found to be free and painless, 
but if traction be made on the contracted muscle, it causes discomfort, 
thus it is usually resisted by the patient. 

In disease of the occipito-axoid region, the distortion of the head is, 
by no means, typical of sterno-mastoid contraction ; it may be tilted 
up or down or laterally to an exaggerated degree. In other words, 




Disease of the middle cervical region at an 
early stage. 



DIAGNOSIS. 55 

the wry neck of Pott's disease is an irregular distortion, not dependent 
on the contraction of a particular muscle or muscular group. " In 
torticollis the chin is turned away from the contracted muscle while in 
Pott's disease it is turned toward the contracted muscle." This is an 
axiomatic expression of the fact that the distortion of the head symp- 
tomatic of atlo-axoid disease, depends, in great degree, upon the spasm 
of the small muscles that directly control these joints, the recti and 
obliqui and not directly upon the contraction of the sterno-mastoid 
muscle, as in the ordinary form of wry neck. Again the contraction, 
symptomatic of Pott's disease, of this or other regions, is the result of 
muscular spasm, a muscular spasm that fixes the head and prevents 
painful motion. If the head be grasped firmly by the hands and if 
gentle traction be made, the muscular spasm relaxes and the patient 
experiences a sensation of comfort, while if similar traction is made 
upon the contracted muscles of simple wry neck, the pain is increased 
and the patient protests. 

In disease of the middle cervical region, however, the distortion due 
to the reflex muscular spasm, is similar to that of simple torticollis, and 
it is sometimes difficult to distinguish one from the other, particularly 
if the latter is caused by the irritation of inflamed or suppurating 
glands. For, in such cases, there is usually much sensitiveness to 
manipulation and a more or less general muscular spasm, so that diag- 
nosis may be impossible, until apparatus has been applied to rest the 
part, and to correct the deformity. 

It has been stated that the head was often tilted backward to com- 
pensate for deformity in the middle cervical region. It is also, in 
some instances, drawn backward by spasm of the posterior muscles. 
Such a case might be mistaken for cervical opisthotonos, in which the 
head is held in an over-extended position, as is sometimes seen in 
young infants suffering from exhausting diseases, basilar meningitis 
and the like. In such conditions, however, the characteristic symp- 
toms of Pott's disease are, of course, absent. 

The opposite attitude, viz., a forward droop of the head due to weak- 
ness of the trapezii muscles, is not uncommon as a sequence of diph- 
theria or other forms of contagious disease. This droop may be 
accompanied also by spasm of one of the sterno-mastoid muscles and 
by pain. In such cases, the history of the preceding affection, the 
weakness or paralysis of other parts, as of the soft palate, the muscles 
of accommodation of the eye and the like, together with the general 
bodily weakness that the patients often present, should make the diag- 
nosis clear. 

Injury to the upper segment of the spine, a sprain, contusion, or 
fracture unless efficiently treated, may cause symptoms resembling very 
closely those of tuberculous disease ; for example, the pain often radi- 
ates over the back of the head, and there may be rigidity and deform- 
ity of the neck, and even infiltration and local tenderness about the in- 
jured part. Such cases, when seen several weeks or months after the 
accident, are puzzling, because one may be in doubt whether the symp- 



56 TUBERCULOUS DISEASE OF THE SPINE. 

toms were caused by a simple injury or whether tuberculous infection 
may have followed or preceded it. In such cases a positive diagnosis 
cannot be made until the effect of rest and protection has been observed, 
that is to say, suspicious cases should be treated as one would treat 
actual disease. If the case is simply one of injury, recovery will be 
rapid and complete, while if disease be present, the symptoms only, 
will be relieved. 

The occipito-axoid articulation may be involved in acute articular 
rheumatism, or in chronic rheumatoid arthritis, when the diagnosis is of 
course easily made, but occasionally the joints at the upper extremity 
of the spine may be the seat of what appears to be an infectious arth- 
ritis, in which the symptoms are of sudden onset and are sometimes 
combined with fever and constitutional disturbance, and in which no 
other joint is involved. The sudden onset and the rapid recovery are 
the diagnostic points. 

Abscess in the cervical region is a secondary symptom, and although 
it may first attract attention to disease by the change in the voice or 
the difficulty in breathing or swallowing, yet it is always accompanied 
by some of the characteristic signs of Pott's disease. 

Whenever the diagnosis of cervical disease is made, one should ex- 
amine the throat, and whenever a chronic retro-pharyngeal abscess is 
present one should look for the symptoms of Pott's disease. 

The diagnosis of the retro-pharyngeal abscess can be made only by 
inspection and palpation ; therefore, one need only mention the fact, 
that symptoms of obstruction in the throat, similar to those of abscess, 
may be caused by adenoid growths and enlarged tonsils. 

Retro-pharyngeal abscess is by no means always symptomatic of 
Pott's disease. It may be acute, as one of the sequelae of contagious 
disease or as a complication of pharyngitis. It is then rapid in its 
onset and is not accompanied by the symptoms of Pott's disease. 

Recapitulation. 

If the disease is of the upper or occipito-axoid region the head is 
usually fixed in an attitude of deformity, which is sometimes slight 
and sometimes extreme. 

In the middle region, the attitude more often resembles that of or- 
dinary torticollis. In the lower region, there is often no marked 
spasm of muscles, but the head hangs backward or toward one 
shoulder. 

The contour of the cervical spine changes as the disease progresses, 
the normal anterior curvature is obliterated, thus the head is pushed 
forward, while the dorsal section of the spine becomes flat or even in- 
curvated in compensation. The seat of the disease is often shown by 
an area of thickening or local tenderness to deep pressure. 

Disease of the joints of the upper or occipito-axoid section is often 
acute in onset, sometimes a form of synovial tuberculosis, and abscess 
is a very frequent complication. 



THE RECORD OF THE CASE. 57 

Differential diagnosis of disease in this region will include the con- 
sideration of the various forms of wry neck, cervical opisthotonos, 
diphtheritic paralysis, and injury. Petro-pharyngeal abscess must be 
distinguished from that not connected with the bone, and from other 
forms of obstruction in the throat. 

Diagnosis in General. 

Weakness and the so-called " loss of walk " are well-known symp- 
toms of Pott's disease, and on this account children suffering from 
different forms of weakness or paralysis are often sent to orthopaedic 
clinics for the treatment of " spine disease." 

Certain forms of paralysis bear a superficial resemblance to some of 
the symptoms of Pott's disease, for example pseudohypertrophic mus- 
cular paralysis to the attitude caused by disease of the lumbar region 
and diphtheritic paralysis to that of the dorsal region. Spastic par- 
alysis, of cerebral origin, resembles somewhat the paralysis of Pott's 
disease, but it may be differentiated by the absence of pain, by the 
history and by what is apparent in most cases, the mental impairment. 

The contractions combined with the weakness and pain that some- 
times follow cerebro-spinal meningitis may be mistaken for the symp- 
toms of bone disease, but are as a rule readily explained by the history 
of the case. 

Forms of organic disease of the spine, other than tuberculous, as, for 
example, malignant disease, syphilis and the like, are described in 
Chapter II. 

The list of affections that has been considered in the differential 
diagnosis, is a long one, but it has been made up from actual experi- 
ence. Most mistakes in diagnosis may be explained by carelessness or 
ignorance, or because of insufficient opportunity for examination ; but 
in the earliest stages of the disease, repeated examinations, time for 
observation and even tentative treatment may be necessary before the 
diagnosis is confirmed. 

The Roentgen Ray Photography as a Means of Diagnosis. — The 
Roentgen ray is of value as a means of determining the exact extent 
of the disease. If the negative is well defined, the diseased vertebrae 
are seen to be irregular in outline or they may be lost in a peculiar 
blur. By counting from above and below the exact extent of the 
disease may be made out, but inferences as to its character and quality 
must be made from the rational and physical signs. 

The Record of the Case. 

The history and the result of the examination of the patient should 
be recorded somewhat in the following order. 

1. The family and the personal history. 

2. The story of the disease with especial reference to its mode of onset, 
its probable duration, to the noticeable symptoms and to previous 
treatment, if any. 



58 TUBERCULOUS DISEASE OF THE SPINE. 

3. The physical examination. This should include the general 
condition of the patient ; the height and weight ; the attitude ; the 
character of the disease, whether acute or otherwise, as shown by the 
muscular spasm and pain on motion ; the presence of abscess as a 
complication, or paralysis ; and finally, the position and extent of the 
disease. This is best shown by a tracing, made by means of a strip 
of lead or pure tin of such thickness that it may be readily moulded 
on the spine and yet hold its shape when removed. Young's device, 
consisting of movable pins set in a frame, is a serviceable appliance 
for this purpose. 

The tracing should be of the entire spine, made while the patient 
lies extended in the prone position, and the exact location of the 
most prominent spinous processes should be marked upon it. In 
determining the position of the disease it is well to count the spin- 
ous processes from below upward, beginning with that of the fourth 
lumbar vertebra, which lies on a line drawn between the highest 
points of the iliac crests. There are other landmarks that are ap- 
proximately correct. Sometimes the last rib may be traced to its 
origin, the scapula covers the second and seventh ribs, the root of the 
spine of the scapula and the middle point of the glenoid cavity being 
on a line with the third, and its inferior angle opposite the tip of the 
seventh dorsal spinous process. The upper margin of the sternum is 
opposite the interval between the second and third dorsal vertebrae. 
The vertebra prominens can often be distinguished, as may the spinous 
process of the axis. 

Such landmarks are, of course, somewhat displaced in deformity, 
but they are always sufficiently correct to check errors in counting the 
spinous processes. 

The history furnishes a foundation on which treatment is conducted 
and from which its results are ascertained. The study of final results 
has become of great importance in orthopaedic surgery, and on this 
account the record should present the condition of the patient when 
treatment is begun, in a form that may be readily understood, not 
only by its writer when details have been forgotten, but by anyone 
who may in after years consult it. To this history notes during the 
course of the disease on its complications and incidents and on the 
changes in the treatment, together with tracings of the spine, are added 
at regular intervals until the patient is cured. 

Treatment. 

The general treatment of tuberculous disease is considered in Chap- 
ter V. Pott's disease is the most important of the tuberculous affec- 
tions of the bones, and the importance of proper surroundings, proper 
food, sunlight, and, within certain limits, exercise in the open air, can 
hardly be exaggerated. 

The General Principles of Mechanical Treatment. — Under normal con- 
ditions the weight of the head and of the thoracic and abdominal 



TREATMENT. 59 

organs tends to bend the spine forward and downward, a tendency 
that is resisted by the action of the muscles of the back. If the re- 
sistance is weakened, as in Pott's disease by the direct destruction of 
the weight-bearing portion of the spine, this tendency toward deformity 
is, of course, greatly increased. Thus the pressure and strain of the 
superincumbent weight upon the weakened part that the upright pos- 
ture entails, are, from the mechanical standpoint, the most important 
factors in the production of deformity. 

When the body is bent forward, as in the stooping posture, the in- 
tervertebral discs are compressed and the pressure upon the vertebral 
bodies is increased ; so, on the other hand, when the body is held erect 
or is bent backward, this pressure is lessened, and a part of the weight 
is transferred to the articular processes and to the posterior parts of the 
column. In fact, specimens show that the continuity of the spine 
may be preserved, and that weight may be supported even when a 
vertebral body has been practically destroyed. 

The object of a brace or other support used in the treatment of 
Pott's disease is to hold the spine in this extended position, so that 
pressure on the diseased vertebrae may be removed. One aims to splint 
the spine as, for example, one would splint a broken back, in order to 
relieve the symptoms of discomfort and pain, so depressing to the patient, 
and to secure the rest that is essential to repair. 

The effectiveness of a particular splint or support, when applied to 
a broken leg or to a diseased spine, depends upon the area that it covers 
on either side of the part to be supported and upon the accuracy of 
its adjustment, as well as upon the damage that the part has already 
sustained, and the strain to which it still may be subjected. 

It must be evident that the body because of its size, shape and 
contents is not suitable for the accurate adjustment of support, and 
it is apparent also that the mechanical conditions are more unfavor- 
able in some parts than in others. For example, in the middle of the 
back the splint is likely to be effective, because its two extremities, at- 
tached to the pelvis and to the shoulders, are equidistant from the 
point to be supported. 

These conditions are reversed in disease of the upper thoracic region, 
because the weight of the head and of the arms tends to increase the 
deformity and because of the insufficient leverage that can be secured 
for the supporting appliance. The pelvis is the base of support for all 
forms of splints, and if it be smaller than the abdomen, as in infancy, 
the adjustment of efficient support is very difficult. 

Although, in actual practice, the treatment of Pott's disease is in- 
fluenced by many circumstances, by the age of the patient, the situa- 
tion of the disease, the duration of the deformity and the like, yet the 
relative efficiency of braces or other appliances may be decided on 
purely mechanical grounds. Thus, as the ultimate deformity of Pott's 
disease is, in great degree, caused by the force of gravity acting on a 
weakened spine, the most effective treatment must be fixation in the 
horizontal position, since only by this means can the strain of use, and 



60 



TUBERCULOUS DISEASE OF THE SPINE. 



the pressure of the superincumbent weight be removed completely ; 
and relief from jars and injury, that favor the extension of the disease, 
be assured. 

Horizontal Fixation. — Apparatus for this treatment must be quite 
independent of the bed on which it may be placed, and of such ap- 
pliances several forms may be employed. 

The reclinationgypsbettes of Lorenz l is simply a posterior case of 
plaster of Paris enclosing the head and body. 

The Phelps bed is somewhat similar. A thin board is cut in the 
outline of the child's body and extended legs. It is padded with 
cotton wadding and covered with cotton cloth ; the patient is then 
placed upon it, and plaster bandages are applied to enclose the body 
and the legs. Later the front is cut away, so that the patient may be 
removed from the bed, for an occasional bath and change of clothing. 2 

The wire cuirasse has been popularized by Sayre ; 3 it is an effec- 
tive appliance although somewhat cumbersome and expensive. 

A more effective and more convenient form of support is the Brad- 
ford frame or stretcher. This is a rectangular frame of ordinary gal- 
vanized gas pipe, or better, of the lighter steel tubing. It should be 
a few inches longer and slightly wider than the patient's body. Over 
the frame, a cover of strong canvas is drawn tightly by means of cor- 
set lacings or straps on its under surface. The center of the cover 
should be protected by a strip of rubber cloth, as will be found to be 

Fig. 27. 




Bradford's bed-frame. (Bradford and Lovett.) 



most convenient in the treatment of young children, who wear diapers ; 
or an interval may be left for the use of the bed pan, as in the illustra- 
tion (Fig. 27) ; or preferably the cover may be made in three parts, of 
which the middle section may be removed when necessary, so that the 
buttocks may not sag into the opening, and thus make the support for 
the spine less efficient. Several sets of canvas covers may be provided, 
to allow for frequent washing ; small linen draw sheets may be used 
to protect them, and a folded sheet or thin hair mattress may be in- 
serted between the layers of the canvas cover, if the straps or lacings 

1 Vide HoSa, Lehrbuch der Orthopadischen Chir., p. 313. 

2 The Phelps plaster-of-Paris bed, Trans. Am. Ortho. Ass'n, Vol. IV., 1891, p. 83. 

3 La gouttiere de Bonnet. Eedard, Chir. Orthopedique, p. 243. 



TREATMENT. 



61 



cause discomfort. These refinements are, however, not essential in 
hospital practice. 

As has been stated, the position of over-extension is that most favor- 
able to repair, and this attitude can be assured by bending the bars up- 
ward from time to time as the deformity recedes, and as the patient 
becomes accustomed to the apparatus. The spinous processes should 
be protected by thick pads extending on either side of the spine at 
the seat of disease. These are sewed to the cover and when properly 
adjusted they assure better support and fixation. 

The method of attaching the patient to the frame varies somewhat 
according to the situation and character of the disease. In ordinary 
cases a canvas apron, similar to that used with the back brace (Fig. 35), 
is applied and is buckled to the sides of the frame, while the shoulders 
are held down by straps crossing the chest, or by axillary straps con- 
nected by a chest band. If still more effective fixation is desired, as 
in disease of the upper dorsal region, the anterior shoulder brace, as 

Fig. 28. 




The modified stretcher splint, showing over-extension of the spine, with traction for the head and 
limbs as applied for Pott's paraplegia. 



used with the back brace (Fig. 33), may be attached to the axillary 
straps. In disease of the upper and middle regions of the spine re- 
straint of the legs is not necessary, but in lumbar disease a broad 
swathe should be passed across the thighs. 

In disease of the upper region of the spine a certain amount of 
traction is desirable to aid in the reduction of deformity and to pre- 
vent the patient from raising the head. This traction is usually ap- 
plied by means of the halter as used with the jury mast. The straps 
are attached to a crossbar at the upper extremity of the frame and 
traction may be made by simply tightening them, or if the upper part of 
the frame is somewhat elevated the weight of the patient's body makes 
the proper extension. This position has the advantage, also, of allow- 
ing the patient a better opportunity to see what is going on about him. 

In disease of the middle cervical region traction is usually of ser- 
vice, and fixation of the head is always indicated in addition when the 
occipito-axoid region is involved, either by sand bags on either side or, 
preferably, by some form of metal brace. 



62 TUBERCULOUS DISEASE OF THE SPINE. 

In the treatment by horizontal fixation, the child, wearing only the 
underclothing, is attached to the frame, and after the apparatus has 
been properly adjusted, he is never allowed to sit up or to turn the 
body or to raise the head until this form of treatment has been discon- 
tinued. Children quickly accustom themselves to a restraint that so 
effectually relieves the symptoms of weakness and pain. 

Once a day, as a rule, the patient is removed from the support in 
the following manner : The frame is placed upon a bed and, the straps 
having been loosened, the child is turned from the frame face down- 
ward upon the bed by two persons, one of whom supports the head 
and shoulders and the other the pelvis, in order that the back may be 
held rigid ; the shirt which opens in front is then removed, the back 
is rubbed gently with alcohol and powdered ; irritated points are care- 
fully protected and bed sores are prevented by padding to remove 
pressure. Usually no trouble whatever is to be anticipated on this 
score. The frame bed is carefully prepared, the draw sheet is changed 
and the canvas cover is tightened if necessary. It is of course a great 
convenience to have two frames so that an immediate change may be 
made from one to the other. 

Greater fixation of the spine may be desirable in cases of more acute 
disease. This may be attained by the use of a light back brace, or a 
plaster jacket, in connection with the frame. Such support should 
not be applied however until the recession of deformity, which is 
to be expected under treatment by the horizontal fixation, has been 
obtained. 

As has been stated the child is placed upon the frame wearing noth- 
ing but the underclothing. The outer garments are made large 
enough to cover both the body and the frame so that a change can be 
made without disturbing the apparatus. Thus protected, the child 
may pass the entire day in the open air. It may be carried in the 
nurse's arms or a carriage may be arranged for it. In colder weather 
the patient may be enclosed in a sleeping bag of blanket or skin. 

Of the conditions that have been mentioned as favorable to the cure 
of tuberculous disease, but one is lacking in the treatment by horizontal 
fixation ; this is exercise. Exercise may be in part replaced by mas- 
sage of the arms and legs, and in any event, beneficial exercise is usu- 
ally out of the question during the phases of the disease for which 
treatment by the frame is indicated. 

Its disadvantages, when properly employed, are in great degree imag- 
inary, while its positive effects in checking the progress of deformity 
and in relieving the symptoms of the disease will be apparent at once. 
The indications for treatment by this method will be considered after 
the description of the other forms of support. 

However efficacious the horizontal fixation apparatus may be, it is 
incomplete in itself since it must be supplemented by some form 01 
support when the erect posture is again assumed. Such supports are 
either metallic braces applied directly to the spine or a form of jacket 
that surrounds the body ; each removes a part of the superincumbent 



TREATMENT. 



63 



weight from the seat of disease by holding the body in the extended 
position and each splints the weakened spine more or less effectively. 

The Back Brace. — The spinal brace, or spinal assistant, as the orig- 
inal appliance of Dr. C. F. Taylor was called, consists essentially of 
two steel bars that are applied on either side of the spinous processes 
from the top to the bottom of the spine. At the seat of disease pads 
are placed to provide for greater pressure and fixation, and thus, a 
fulcrum over which the spine may be straightened or held erect, when 
the two extremities of the brace 

are firmly attached to the pelvis Fig. 29. 

and to the shoulders. The 
attachment at the lower end is 
made by means of a pelvic band 
of sheet steel (gauge 18) from 
one and a-half to two inches in 
width, long enough to reach 
from one iliac spine to the 
other; it is placed as low as 
possible on the pelvis, in other 
words, just above the upper 
extremities of the trochanters. 
To this the uprights are firmly 
attached at an interval of from 
one and a-quarter to one and 
three-quarter inches from one 
another, so that the spinous 
processes may pass between 
them, while pressure is made 
on the lateral masses of the ver- 
tebra?. The uprights are made 
of varying strength, according 
to the age of the patient, usu- 
ally about one-half an inch in 
width (of gauge 8 to 12) and 
of such quality of steel, that 
although unyielding to the 
strain of use, it may be readily 
bent by wrenches, and thus 
accurately adjusted to the back. 

The uprights reach to the root of the neck, or to about the level of the 
second dorsal vertebra ; from this point two short arms of metal pro- 
ject forward and outward, on either side of the neck, reaching to about 
the middle of the clavicles. To these, padded shoulder-straps are at- 
tached, which pass through the axillae to a crossbar on the back brace ; 
thus downward pressure on the shoulders is avoided and increased 
leverage is assured. (Fig. 29.) 

Opposite the point of disease, two strips of thin steel about three 
inches in length are fixed ; these are slightly wider than the uprights 




The Taylor brace and bead support applied for disease 
of tbe upper dorsal region. 



64 



TUBERCULOUS DISEASE OF THE SPINE. 



Fio 



and are perforated for the attachment of the pressure pads. They may 
be made of layers of canton flannel or felt, or unyielding material, 
such as leather or hard rubber, may be used instead. The pads should 
project from a quarter to a half inch in front of the uprights, in order 
that firm and constant pressure, to the extent that the skin will tolerate, 
may be made at the seat of disease. 

In measuring for this brace the patient is placed in the prone posture 
and a tracing of the outline of the back is made by means of the lead 

tape. This outline may be cut in card- 
board and fitted to the back ; in fact, 
if the mechanic is unfamiliar with the 
work, each part of the brace, uprights, 
pelvic band, etc., may be cut in card- 
board and attached to one another to 
serve as a model. Before the brace is 
finished it should be applied; to the 
back and should be carefully adjusted 
by means of wrenches. The pelvic 
band is then padded and the parts 
that come in direct contact with the 
skin are usually covered with leather, 

Fig. 31. 





The Taylor back brace 



Taylor.) 



The Taylor chest piece. Two triangular pads of hard 
rubber connected by a bar. 



or, in the treatment of young children, with rubber plaster and canton 
flannel to prevent rusting. 

If the brace is applied before the stage of deformity, it should fol- 
low the exact shape of the spine, but if deformity is already present, 
particularly in disease of the thoracic region, it should be made some- 
what straighter, in order to permit a gradual correction of the com- 
pensatory lordosis in the lumbar region, and for increased leverage 
above the deformity. As has been stated, a certain amount of reces- 
sion of deformity can be obtained by rest in the horizontal position, 
and if practicable this improved contour should be attained before the 
brace is applied. The apparatus is held in place by an " apron " 



TREATMENT. 



65 



(Fig. 35) which covers the chest and abdomen, to which straps are 
attached. Ordinarily this is made of strong linen or cotton cloth, but 
a canvas front shaped accurately to the body and strengthened with 
whale bone, is a much more comfortable and efficient support. In ap- 
plying the brace the pelvic band is first attached to the apron, then 
the straps in order, from below upward, and finally the shoulder straps. 
Each strap is tightened until the brace is firmly fixed in proper posi- 
tion. When a brace is properly applied and properly fitted, it holds 
its place by friction, but in certain cases, when the disease is low in 
the back, it is sometimes of advantage to apply perineal straps to hold 




Fig. 33. 





Backward traction on the shoulders 
upper dorsal region. 



The anterior shoulder brace and its attachment. 



the pelvic band firmly in its place. (Fig. 30.) At first, the brace is 
removed once a day in order to wash and powder the back, the same 
care being observed in moving the child as in the treatment by the 
frame, but when the back has become accustomed to the pressure, the 
brace should be removed only at infrequent intervals, and thus if de- 
sirable, only under the supervision of the surgeon. 

This description indicates the essential qualities of the back brace. 
It has been modified in various ways ; for example, Dr. Taylor long 
since discarded the straight pelvic band in favor of one of a jj shape. 
(Fig. 30.) This makes the brace somewhat lighter and relieves the 
sacrum from pressure, but it does not add to its effectiveness. The 
efficiency may be increased however by improving the attachment at 
5 



66 



TUBERCULOUS DISEASE OF THE SPINE. 



its upper extremity. Taylor has done this by placing twof trian- 
gular pads against the chest as shown in the diagram. (Fig. 31.) 
Schapps uses in place of the apron an anterior frame of metal, 
counter pressure on the chest being provided by means of a broad 
pad of perforated sole leather. At the lower part a band of metal 
crosses the body and pressure is made directly on the anterior borders 
of the pelvic bones. 

Each method is an improvement on the simple shoulder straps of the 

Fig. 34. 




The Taylor back brace and head support combined with the Whitman anterior support. 



original brace, but neither provides the quality of support and fixation 
that is required, when the disease is of the upper and middle segment 
of the thoracic region. In such cases the upper part of the chest is 
flattened, the inclination of the ribs is increased and the shoulders in- 
cline forward, carrying with them the scapulae. Thus the weight and 
the strain of the motion and use of the arms tend to increase the 
deformity. 

In health, direct forward or reaching movements of the arms are 
always accompanied by an increase in the posterior curvature of the 



TREATMENT. 



67 



dorsal spine. On the other hand if the shoulders are drawn backward 
and held in this attitude, the curvature of the spine is lessened and 
the chest is elevated and expanded. (Fig. 32.) 

In the treatment of disease of the upper dorsal region it should be 
the aim, in the application of a brace, to follow this indication and to 
apply pressure directly upon the extremity of the shoulders to assure 
the greatest possible fixation of the spine and to restrain the move- 
ments of the arms, that tend to increase the deformity. 

The accompanying diagrams (Fig. 33) show how such support may be 
applied. Two saucer-shaped plates of hard rubber or padded metal 



Fig. 35. 




Fig. 36. 



The anterior shoulder brace. 




'he scapular pads 



cover the heads of the humeri and are joined by a rigid bar of steel which 
passes across but does not touch the chest. On the back brace are placed 
two triangular pads of similar construction which cover and press 
upon the scapulae. These pads are however not essential and are often 
omitted. The back brace is applied, the shoulders are then drawn 
backwards and the shoulder cups are firmly attached by straps to the 
neck bars of the brace above and below by axillary bands in the usual 
manner. By this means the thorax is elevated and the spine is more 
eifectively fixed, while direct movement of the arms forward is made 
impossible. It would seem that such restraint would be irksome to 
the patient, but in an extended use of the apparatus this has never 
been complained of. In many instances, even when the disease is as 
low as the tenth dorsal vertebra it may be used with advantage but it 



68 



TUBERCULOUS DISEASE OF THE SPINE. 



is especially indicated when the disease is in the neighborhood of the 
seventh dorsal vertebra. In connection with the shoulder brace it is 
usually advisable to apply a support beneath the chin to prevent the for- 
ward inclination of the neck and to tilt the head somewhat backward. 
A very simple and inoffensive support of this character is a loop of 
steel surrounding the neck and attached by screws to a back bar on the 
brace. (Fig. 37.) If a more efficient brace is required, as when the 
disease is of the upper dorsal or cervical regions, the Taylor head sup- 
port should be used. This is 
an oval ring of steel which 

may be clasped about the neck fig. 38. 

by means of a lateral hinge. 
On the front a cup of hard 
rubber supports the chin and 
behind the ring fits upon an 
upright pivot, that may be 
raised or lowered upon a cross- 



Ftg. 37. 





The loop head support. 



Disease of the middle cervical region, show- 
ing deformity and attitude. This patient had 
heen paralyzed for one year before treatment 
was begun. (See Fig. 39.) 



bar on the upper part of the brace ; free lateral motion is allowed or 
it may be checked by means of a screw. (Figs. 34 and 39.) 

If absolute fixation of the head is indicated as in disease at or near 
the occipito-axoid region two steel uprights may be attached to the 
back of the ring and are bent to fit the posterior and lateral aspect of 
the head closely and a band of webbing is passed from one upright 
to the other and about the forehead. 



TREATMENT. 



6a 



In applying the support the chin should always be tilted slightly 
upward in order to throw the weight of the head backward. (Fig. 39.) 

The adjustment of the head support is made easier if the pivot is 
attached to the upright by means of a ball and socket joint (Shaffer) 
(Fig. 29) that may be regulated by a screw and key ; this arrangement 
is of service when the head is distorted but it is by no means necessary. 



Fig. 39. 



Fig. 40. 





The Taylor brace and head support applied 
to the patient shown in Fig. 38. 



The Taylor brace with jury mast. 



When the Taylor head support and similar appliances are used the 
greater part of the pressure is sustained by the chin which may, after 
a time, undergo an unsightly recession. It may be of advantage there- 
fore in certain cases, particularly when restraint of the motion of the 
neck is desirable to transfer this pressure to the forehead and occiput 
by extending the back bars upward over the back of the head as in 
Fig. 47. 



70 TUBERCULOUS DISEASE OF THE SPINE. 

A jury mast may be used to support the head also ; its adjustment 
will be described in connection with the plaster jacket with which it is 
usually associated. (Fig. 40.) 

The Plaster Jacket. — It was at one time claimed that a plaster jacket 
applied while the body was partially suspended, would actually relieve 
the weakened area of superincumbent weight, by holding the dis- 
eased surfaces apart. This is not the fact. The jacket supports the 
spine as does the brace, by holding it in the erect or exteuded position. 
One is a circular and the other is a posterior splint. There is this 
difference however, the brace fits the spine accurately and holds its 
place by pressure and friction ; the jacket is held in place by the sup- 
port of the projecting pelvic bones ; it lacks the accuracy of adjustment 
of the brace at the seat of disease, but on the other hand it provides a 
solid support on the front and sides of the body. 

Each appliance has advantages and disadvantages that become ap- 
parent in the treatment of certain phases of the disease or conditions 
of the patient. 

The plaster bandage is a simple support, whose efficiency depends 
upon the accuracy of its adjustment to the irregularities of the body, 
and upon the leverage that it exerts above and below the point of 
disease. It should be applied while the body is held- in the best pos- 
sible position ; its inner surface should be smooth, and the bony promi- 
nences that are susceptible to friction and pressure should be protected. 

A seamless shirt should be worn ; these are made in several sizes 
and are sold by the yard at a low price. The shirt should fit the body 
closely and should be long enough to reach to the knees. The patient 
is then placed upon a stool, and the halter of the suspension apparatus 
is carefully adjusted ; the arms are extended over the head and the 
hands clasp the straps or rings ; thus the chest is expanded to its full 
limit. Sufficient tension is made upon the rope to partially suspend 
the body and to draw the spine into the best possible attitude ; in most 
instances the heels should be slightly lifted from the stool. 

Dr. Sayre, to whom we are indebted for the exposition of this valu- 
able means of treatment, insists that the sensations of the patient should 
be the guide, and that traction should be made only to the point of 
comfort. This is a valuable indication in the treatment of the adult, 
but it is not often of service in childhood. 

Before applying the plaster bandage, pieces of piano felting or 
canton flannel of sufficient size are placed about the anterior pelvic 
spines, over the upper part of the sternum and a thin strip is some- 
times used to cover the spinous processes. Finally long strips of 
saddler's felt, or of other material of sufficient thickness, are applied 
on either side of the prominent spines to protect them from friction 
and to provide greater pressure and fixation at the seat of disease. 
The " dinner pad " is now very rarely used, except in the treatment of 
adults, and in certain cases of deformity, in which the abdomen is 
retracted. In childhood the abdomen is usually prominent, and as the 
jacket expands somewhat after its application no extra space is re- 



TREATMENT. 71 

quired. The pad, which is supposed to represent the space necessary 
after a full meal, is made by folding a small towel into the shape 
of a sandwich ; this is attached to a bandage and is placed beneath 
the shirt just below the ensiform cartilage ; when the jacket is com- 
pleted it may be drawn out, by means of the hanging bandage, leaving 
the additional space for emergencies. 

The materials for the jacket should be of the best. Fresh dental 
plaster should be rubbed by hand into strips of crinoline, free from 
glue. The bandages should be from three to five inches in width, and 
six yards in length ; from three to six being required for a jacket, ac- 
cording to the size of the child. They should be placed on end, in a 
pail of warm water, one at a time as they are used. ISTo salt or alum 
should be used to hasten the setting of the plaster, in fact, if such aid is 
necessary, it is unfit for use. When the bubbles have ceased to rise, 
the bandage is squeezed gently until no water drips from it and the loose 
threads are removed from the ends. 

One person should sit behind the patient, and one in front, while a 
third may hold the rope and check the swaying of the body. The one 
who sits behind the patient may clasp the child's legs between his 
knees and thus assure better fixation of the pelvis. The pads are held 
in position until they are fixed by the plaster bandages, which should 
be applied with a slight and even tension. 

As a rule the jacket should be of uniform thickness throughout. 
This thickness need not exceed one eighth to one-fourth of an inch 
and it may be even lighter in certain cases. It is well to make the 
first turns about the waist and to use the first bandage about the pelvis 
since the pelvis is the base of support ; and as the most important 
point for counter pressure is the chest, this part should be made espe- 
cially strong. 

During the application of the jacket it should be rubbed constantly, 
in order that the different layers of bandage may adhere to one another, 
and that it may fit the projections of the pelvis and body closely. 
Meanwhile the attitude of the patient should be carefully watched, in 
order to prevent lateral inclination of the body. In some instances it 
is possible to lessen the deformity in the dorsal region, by the exten- 
sion, and by backward traction on the shoulders, while the jacket is 
hardening. 

When the jacket is nearly firm, it should be trimmed. In many 
instances this may be done while the patient is in the swing, but if he 
is fatigued he may be placed in the recumbent posture. 

As a rule the front of the jacket should reach from the upper mar- 
gin of the sternum to the pubes ; behind, from the spines of the scap- 
ulae to the gluteal fold ; laterally it should be cut away sufficiently to 
prevent chafing of the arms ; and on either side of the pubes an oval 
section is cut out, to allow for the flexion of the thighs in the sitting 
posture. Particular attention is called to the importance of making 
the jacket as long as possible, so that the abdomen may be contained 
within it, instead of being forced out beneath its lower border. (Fig. 



72 



TUBERCULOUS DISEASE OF THE SPINE. 



42.) After the application of the jacket, the patient should remain in 
the recumbent posture for at least half an hour. A much longer period 
of recumbency is always advisable as it does not become absolutely firm 
for several hours. The shirt is then drawn up over the jacket and is 
sewed to the neck portion ; this adds much to neatness and cleanliness. 
The shirt must be drawn tightly about the neck, in order to guard 



Fig. 41. 



Fig. 42. 





The plaster jacket. 



The plaster jacket supporting the abdomen. 



the body from the crumbs or other objects that may fall beneath the 
jacket, and in many instances a special protector in the form of a wide 
collar bib, may be used with advantage. (Fig. 41.) 

It may be mentioned in this connection that even the slightest ex- 
coriation or irritation of the skin beneath the jacket, can be at once 



TREATMENT. 



73 



detected by the peculiar odor. Of this parents should be informed, 
so that it may be cut down and the source of the irritation removed 
at once. With ordinary care, 

" sores," the bugbear of the Fl «- 43 - 

plaster jacket, are of little con- 
sequence. 

If the disease is of the mid- 
dle region of the spine, back 
ward traction on the shoulders 
is indicated, by means of the 
anterior shoulder brace de- 
scribed in connection with the 
spinal brace. (Fig. 43.) 

In many instances a head 
support is required, and it is 
of course always indicated in 
disease of the upper dorsal and 
cervical regions. For this pur- 
pose the jury mast is most 
often employed. 

The jury mast should be of 
tempered steel, strong enough 
to hold its shape under the ten- 
sion of the halter. (Fig. 44.) 
Its base should be incorpo- 
rated firmly in the jacket below 
the seat of disease ; it should 
be long enough to reach well 
above the head and the crossbar should be placed directly over the 

ears. (Fig. 45.) 

Fig. 44. 




The jury mast and the anterior support. 




Jury mast. 



The halter should be applied with as much tension as can be borne 
comfortably by the patient, so that the weight of the head may be at 



74 TUBERCULOUS DISEASE OF THE SPINE. 

least partly supported and the chin should be tilted slightly upward, 
the aim being to draw the head backward and thus to extend the spine. 
In disease of the cervical region the crossbar should be fixed to check 
lateral motion of the head, but this is unnecessary when the disease 
is at a lower level. 

The Application of the Jacket in the Recumbent Posture. — The jacket 
may be applied while the patient lies extended in the prone posture, 
by the hammock method suggested by Davy of London. 

Fig. 45. 




The jacket and jury-mast applied. The same patient is shown in Fig. 28. 

A*long narrow strip of cotton cloth is passed under the shirt and 
the two extremities are drawn tight enough, by means of a pulley, to 
support the child in the proper attitude. An opening is cut for the 
face and, if advisable, traction may be made on the arms and legs of 
the patient. The bandages are then applied in the ordinary manner 
after which the cloth may be cut short at one end and removed. 

This procedure is of service in the treatment of weak or paralyzed 
patients, but the adjustment is somewhat less accurate than by the 
ordinary method. The jacket may be applied in the supine posture 
by means of the Goldihivait support. This latter method may be em- 
ployed with advantage in the routine application of the plaster jacket. 
(Fig. 46.) 



TREATMENT. 



75 



The Application of the Jacket to Patients who have been Treated on 
the Stretcher Frame. — A very satisfactory method of applying a plaster 
jacket in young subjects, whose deformity has been corrected in whole 
or part by recumbency on the frame in the over-extended position, is 
the following. The patient is suspended face downward in the hori- 
zontal position by two assistants, one holding the arms and the other 
the thighs ; thus a certain amount of traction is exerted while the 
weight of the body tends to over-extend the spine. 

In this attitude a jacket is quickly applied, and the child is at 
once replaced upon his frame which has been protected by a rubber 

Fig. 46. 




The routine method of applying the plaster jacket in the horizontal position by means of the 
Goldthwait appliance. The essential part of the apparatus is shown in duplicate in" the foreground 
(A). Upon its upper extremities two thin bands of steel, similar to those used in the Taylor brace, 
are placed (B), to support the pads which protect the spinous processes at the deformity. The child is 
placed upon the support, as illustrated in the figure, and the plaster bandages are carried about the 
body on either side of the support, including the pads. When the jacket is firm the patient is lifted 
from the support. By this method a certain amount of leverage is exerted upon the deformity, but 
less than when the other forms of the appliance are used. See Figs. 58, 59 and 60. 



sheet. Thus the plaster jacket, during the hardening process, must 
conform to the habitual posture of recumbency. In addition, the 
pressure pads of the frame indent the bandage on either side of the 
spinous processes (Fig. 48) and thus assure better support and fixa- 
tion. This is a very effective method of applying the jacket in this 
class of cases, because it is not necessary to retain the child in an un- 
comfortable position while the bandage is hardening, and because ac- 
curacy of adjustment in the best possible attitude is assured. 

As a rule a jacket may be worn for two months, although not infre- 
quently in hospital practice it may remain for six months, or even 



76 



TUBERCULOUS DISEASE OF THE SPINE. 



longer, and yet be fairly efficient. Usually one jacket is removed and 
another applied on the same day, but if the skin is at all sensitive it 
is well, after the washing and powdering, to re-apply the old jacket, 
closing it with adhesive plaster, and allow an interval of a few days 
before applying the permanent one. 

The Plaster Corset. — In the stage of recovery the jacket may be re- 
placed by a corset. A jacket, made and trimmed as already described, 
is cut down the center and removed from the body. It is carefully 



Fig. 47. 




Fig. 48. 




A fixation support for the head. This may be 
used with the brace or with the jacket. 



Jacket applied by the stretcher method, showing 
the depressions in "the jacket caused by the frame 



readjusted to its former shape, bandaged with the cut surfaces in close 
apposition, and is thoroughly dried or baked. All wriukles are then 
cut away from the inner surface, and extra padding is applied if neces- 
sary ; the shirt is drawn tightly about the borders of the jacket and 
strips of leather provided with hooks are sewed in front so that it may 
be laced like an ordinary corset. It may be removed, from time to 
time, to allow for bathing, but it should always be removed and re- 
applied while the patient is suspended or in the recumbent position. 
Corsets are often used in place of the jackets in the treatment of the 



TREATMENT. 11 

active stage of the disease, but they are less effective, since the repeated 
stretching during their removal and reapplication weakens them and 
impairs the accuracy of adjustment ; and, in addition, one of the strong- 
est arguments in favor of the use of plaster of Paris, that treatment is 
under the control of the surgeon, is nullified. 

Comparison of the Two Forms of Ambulatory Support. — The most se- 
vere criticisms of the jacket have been made by those unfamiliar with 
its use, on theoretical grounds rather than from actual observation. 
While it is admitted that there are certain objections to its use, yet 
experience shows that when it is applied in a proper manner under 
proper conditions it is a thoroughly reliable, efficient and often indis- 
pensable means of treatment. Indeed, it may be stated that by means 
of the jacket and the Bradford frame it is possible to treat nearly every 
case of Pott's disease without the aid of the professional bracemaker, 
and with success. 

It is evident, however, that under certain conditions the jacket must 
be inferior to the brace, in early childhood, for example, when the 
pelvis is not sufficiently developed for proper support. Again when 
the disease is low down, at or near the lumbo-sacral junction, the 
lower border of the jacket does not hold the pelvis with sufficient 
security to provide the proper fixation. In the upper dorsal region 
the attachments for accurate fixation may be more readily applied to 
the brace, and in disease of the cervical region the metallic head 
support is to be preferred to the jury mast, for the reason that it 
cannot be removed by the patient as can be the straps of the halter. 
The traction of the jury mast is very effective when properly used and 
particularly so, when painful distortion of the head is present, but the 
tension on the straps is rarely constant and thus it loses in effective- 
ness. A rigid support is, of course, essential in disease of the atlo- 
axoid region. 

The jacket will be found to be most efficient in disease of the spine 
from the tenth dorsal to the second lumbar vertebra. It is not only 
effective but it is often a more comfortable support than the spinal 
brace. It is also more efficient than the brace when lateral deviation 
of the spine is present ; and from the clinical standpoint, it is often 
more efficient in relieving the symptoms of pain in this region, when 
the disease is at all acute. 

One may conclude, then, that each form of support may be used ac- 
cording to the indications. The absolute control of the treatment, 
assured by the use of the plaster jacket will often over-balance the 
claims of the brace ; in practice among the poor, when choice of means 
is not always permitted, it is indispensable ; and it may be used with 
fair success, even under conditions that theoretically contraindicate its 
employment. 

Modifications of the Jacket. — Occasionally, the form of the jacket may 
be changed to meet special indications ; for example, backward traction 
may be secured by carrying the bandages over the shoulders ; or the 
head may be fixed in the support, if the jury mast is not at hand (Fig. 



78 



TUBERCULOUS DISEASE OF THE SPINE. 



49) ; or one or both thighs may be included in a spica jacket in painful 
disease of the lower region, when psoas spasm is a symptom. Such 
modifications are required rather for temporary emergencies than for 
continuous treatment. 

Dr. H. L. Taylor has recommended what he calls the bivalve plas- 
tic splint of plaster of Paris. 

" A paper pattern of the posterior valve is made from the patient's 
back allowing one inch extra around the edge to be folded back. 
From this pattern eight or ten thicknesses of crinoline are cut of the 
same size and shape. The patient being supported face downward on 

a rest under the pelvis and 
Fig. 49. another under the upper part 

of the sternum, the crinoline 
sheets are dipped into plaster 
cream in a large flat pan, 
applied to the back, the felt 
pads being in position ; the 
edges are folded back for 
greater rigidity and the whole 
carefully moulded to the pa- 
tient and allowed to set, after 
which the patient is turned 
on his back and the anterior 
valve made in a similar 
manner. 

" The jacket should be 
made firm and rigid, especi- 
ally at the edges, and should 
reach in front from the pubes 
to the top of the sternum. 
Such an apparatus is rigid, 
removable and adjustable and 
brings the pressure to bear on 
definite areas selected with 
regard to its mechanical ac- 
tion. The splint may be re- 
moved to cleanse the back or 
to note its efficiency, taking 
the impressions made by the 
felt pads either side the 
spinous processes as a guide. 
If more leverage is needed, the felting may be reinforced or the depth 
of casing reduced by paring the lateral edges. In other words the 
jacket has ceased to be mainly a casing and has become a mechanism 
under the surgeon's control and capable of being manipulated to pro- 
duce definite mechanical results." 

Corsets of Other Material than Plaster of Paris. — Corsets of wood, 
leather, paper, poro-plastic felt or celluloid are sometimes used. These 




Plaster bandage including the head to hold the 
spine in the extended position after the correction of 
deformity. 



TREATMENT. 



79 



are constructed on a plaster cast of the body, a thin accurately fitting 
jacket being used as a mould. 

Such corsets have certain advantages of durability, and elegance, 
but none of them has the accuracy of fit of the plaster of Paris corset, 
which is moulded directly on the body by constant manipulation during 
the stage of solidification. Corsets of this class are usually somewhat 
expensive, and on that account are often worn after they are outgrown 
or no longer fit the patient. Their use is practically limited to the 
stage of recovery or for other affections than Pott's disease. 



Fig. 50. 




The Thomas collar. (Ridlon and Jones.) 

Of these corsets, one of the best is that used by Weigel, of Eoches- 
ter, made of alternate layers of linen cloth and wood pulp matrix paper, 
fixed by a mixture of paste and glue. 

A more durable corset may be constructed of aluminum, as advocated 
by Phelps. This may be obtained in thin sheets, which may be ham- 
mered upon the plaster cast into the proper shape. The two halves 
are attached by hinges in the back and are perforated to allow for 
ventilation. 

In the final stage of treatment, the Knight brace, a light steel frame 
with corset front may be employed (Fig. 132), or a long corset similar 

Fig. 51. 




The Thomas collar. A piece of thin sheet metal is cut wide enough to reach from the sternum 
to the chin and from the back of the neck to the base of the occiput. The edges are turned out 
and the whole properly covered with felt and fitted. (Bjdlon and Jones.) 



to that ordinarily worn by women, but strengthened by the insertion 
of light steel bars along the spine, is often sufficient. 

Other Forms of Support. — In certain cases of disease of the lower 
lumbar region of the spine, it may seem advisable to restrain the 
movements of the thighs, although ordinarily, when this is necessary 
the patient should be placed upon the frame. Such restraint may be 



80 



TUBERCULOUS DISEASE OF THE SPINE. 



Fio. 52. 



attained by making the back bars of the brace stronger and extending 
them down the back of the thighs to the knees like a double Thomas 
hip brace. 

If the jacket is used, it may be extended to a single or double spica 
for the same purpose, as has been mentioned. Such appliances are use- 
ful when psoas spasm and " cramp " are troublesome symptoms. 

In disease of the cervical region a certain amount of support and 
fixation may be obtained by collars of poro-plastic felt, plaster of Paris 
or other material. The Thomas collar is the best of this type of sup- 
port, but none of them is thoroughly efficient unless used with a 
brace to control the larger movements of the spine. They are use- 
ful in emergencies but they are 
not often required when proper 
braces can be obtained. 

Many other forms of appa- 
ratus of greater or less merit 
might be described, but space 
has only permitted a detailed 
account of three forms that, it 
would seem, best represent the 
essential principles involved in 
the treatment of Pott's disease. 
The Principles of Treat- 
ment in Their Practical Ap- 
plication. — After the descrip- 
tion of the special forms of 
appliances used in the routine 
treatment of Pott's disease, one 
may consider with advantage 
the treatment in its more direct 
relation to the patient. The 
object of this treatment is to 
relieve the symptoms, to main- 
tain and to improve the vital 
resistance of the patient, to 
check, to remedy and to prevent deformity. Under favorable con- 
ditions the death rate is small, and pain is easily relieved, but preven- 
tion of deformity is often extremely difficult. 

The effect of treatment must be estimated not simply by its relief 
of the symptoms of the disease, since deformity may steadily advance 
in spite of the apparent well-being of the patient, but it must be se- 
lected and continued or changed with the aim of combating ultimate 
deformity, and on this standard success or failure must be determined. 
It is probable that noticeable deformity might be prevented, nearly 
always, if treatment were applied in season. But practically such 
opportunity is not often offered, and the local deformity that represents 
destruction of bone, may be considered as irremediable. There is also 
a dwarfing and blighting effect of the disease, which, although it is 




The Thomas collar applied. (Ridlon and Jones. ) 



PRINCIPLES OF TREATMENT IN PRACTICAL APPLICATION. 81 



usually associated with marked deformity, is always to be feared, par- 
ticularly when the disease affects the middle or lower region of the 
spine in early childhood, and is severe and prolonged in its course. 
By proper treatment one may hope to check the progress of the dis- 
ease and even to remedy the deformity in great degree, by freeing the 
spine from the deforming influence of local disease, and by preventing 
or removing the symptomatic distortions 
such as psoas contraction or wry neck. Fig. 53. 

Indications for Treatment by Recumbency. 
— As has been stated already, the most 
important influence toward deformity when 
the spine has been weakened by disease, is 
the force of gravity ; therefore horizontal 
fixation is the most efficient means of pre- 
venting deformity, and it assures the rest 
for the diseased spine that favors repair. 

This is then the treatment of last resort, 
the treatment for emergencies and in many 
instances the treatment of choice and rou- 
tine. It is indicated as the routine treat- 
ment in infancy, and in early childhood up 
to the age of three years, at least during the 
acute and progressive stage of the disease, 
because the structure of the spine offers but 
little resistance to the extension of the des- 
tructive process, and because prolonged di- 
sease and deformity are much more dis- 
astrous at this age of rapid growth than at 
a later period. 

The time that this treatment should be 
continued is determined by the character of 
the disease, by the presence or absence of 
complications and above all by the condition 
of the patient. A year would perhaps repre- 
sent the average time that horizontal fixa- 
tion may be employed with advantage in 
appropriate cases. When the frame is used 
in the manner described, and when the child 
is taken regularly into the open air, the 
general condition almost always improves 

with the complete relief of the pain, weakness and discomfort that the 
treatment assures. 

If the progress of the local disease is toward repair, the patient 
becomes restless, he no longer lies motionless when he is removed 
from the frame, but turns and twists the body in a manner that 
shows the absence of muscular spasm. At this time it is well to 
fit the back brace that is to be used when the frame is discarded, 
provided it has not already been used in conjunction with the hori- 
6 




Final result of lumbar disease; spon- 
taneous absorption of abscess, and 
but sligbt deformity. See Fig. 13. 



82 



TUBERCULOUS DISEASE OF THE SPINE. 



zontal fixation ; then little by little the upright posture and ambulation 
are resumed. 

Fig. 54. 





• .'** 






m 


-. 




■ % 






E j 











Pott's disease of the middle dorsal region, a type of disease in which horizontal fixation is always 
indicated. H. S., age 14 months. 

In many instances absolute recumbency may not be required, but 
the period of activity must be carefully regulated, and must be discon- 

Fig. 55. 




H. S. after 14 months of fixation on the modified Bradford frame, shows the recession of deformity. 

Compare with Fig. 54. 



SPECIAL INDICATIONS FOR TREATMENT. 83 

tinued when there is evidence of discomfort or weakness or pain. If 
the period of activity must be short, it should be passed in the open 
air. The passive attitude of sitting, although less strain is thrown 
upon the spine than during activity, may be even worse for the pa- 
tient ; thus the reclining or semi-reclining posture should be assumed, 
as a rule, when the child is in the house, at least during the active 
stage of the disease. Even if the patient appears to be perfectly sup- 
ported, the time spent in bed should be long, and a period of rest in 
the middle of the day should be enforced. 

The arguments in favor of horizontal fixation in early childhood do 
not apply to disease in the adult. At this age the structure of the 
spine is resistant, and deformity is little to be feared, while such con- 
finement would be irksome and impracticable ; thus local support, 
supervision and, if possible, a change of climate, must be the treat- 
ment of selection for the adolescent or adult. 

In the middle period, from the third to the tenth year horizontal 
fixation is the treatment for emergencies ; for paralysis, for abscess, 
for dangerous disease of the atlo-axoid region, for progressive deformity, 
and for pain that cannot be relieved by the ordinary means. 

Special Indications for Treatment of Disease of the Different 
Regions of the Spine. 

In the selection of treatment, and in the general management of 
Pott's disease each region of the spine must be judged by itself, since 
in each there are special difficulties to be met, and complications to be 
feared, that may influence the prognosis and lead to modifications of 
the routine of treatment. 

The Lower Region. — The prognosis is good in disease of the lower 
region, the symptomatic attitude is favorable, the part may be easily 
supported, the cases are often seen before the deformity is at all ex- 
treme, and one may, as a rule, predict recovery without noticeable de- 
formity or at most a slight shortening and broadening of the body and 
a peculiar erectness of attitude. 

Uncomplicated cases may be treated with the brace or jacket. The 
brace is the better support when the disease is near the sacrum, 
while the jacket is often more comfortable and more effective than 
the brace when the middle and upper lumbar region is diseased, par- 
ticularly when lateral deviation of the spine is present. When- 
ever the tendency to psoas contraction is at all marked or when pain 
or cramps in the legs are complained of, the period of activity should 
be carefully restricted ; in fact the " night cry " is an indication for a 
day of rest in bed. 

The most troublesome complications of this region are psoas con- 
traction and the abscess with which it is often combined. 

As has been stated, psoas contraction changes the attitude of over- 
erectness, favorable to repair, to a forward stoop that increases the 
pressure and friction at the seat of disease. If this attitude persists 



84 TUBERCULOUS DISEASE OF THE SPINE. 

and if it becomes fixed by permanent changes such as are likely to 
follow the burrowing of a pelvic abscess, the result is one of most 
disastrous deformity, the body and the legs are approximated and the 
erect attitude is made impossible. In neglected cases of this char- 
acter, tenotomy and forcible correction or even subtrochanteric osteot- 
omy may be necessary to overcome the secondary deformity. 

In ordinary cases of psoas contraction, and when one leg only is 
flexed, the patient may be allowed to go about using a high shoe on 
the unaffected side and crutches, so that the flexed leg need not affect 
the attitude. If, however, the contraction persists, it is well to place 
the patient on the frame, and to reduce the flexion by traction in the 
line of deformity, as will be described in the treatment of disease of 
the hip joint. Persistent psoas contraction is almost always a symptom 
of abscess about the origin or in the substance of the muscle, and when 
it is accompanied by pain, it is always an evidence of active disease. 

Abscess may be expected as a complication in at least 50 per cent, 
of the cases of disease of this region, but it is by no means always 
accompanied by psoas contraction, any more than psoas contraction is 
always caused by abscess. Abscess unaccompanied by contraction 
more often has its origin above the lumbar region, so that in its descent 
it passes along the surface but does not involve the substance of the 
muscle. 

Attention is especially called to the fact that the bad results of Pott's 
disease of this region are almost invariably caused by allowing flexion 
of the legs, whether it be symptomatic of abscess or not, to persist, 
therefore the importance of preventing and correcting this deformity 
cannot be over-estimated. It should be stated, however, that in dis- 
pensary practice, when special care cannot be provided, one often sees 
psoas contraction that may have persisted for months relax, if the 
progress of the disease is favorable, without treatment other than the 
routine fixation of the spine by the brace or jacket. In certain cases, 
one or both thighs may be fixed by the plaster bandage or by the back 
bars attached to the brace, when pain and spasm are troublesome, but 
as a rule rest on the back until the acute phase of the disease has 
passed is to be preferred. 

The Lower Dorsal Region. — Disease of the lower dorsal region, the 
middle of the back, is very favorably situated for effective mechanical 
treatment, and psoas contraction and abscess are much less troublesome 
than in the lower part of the spine. The brace or the jacket is an 
efficient support, and the symptoms are, as a rule, easily relieved. 

Deformity sometimes increases, almost imperceptibly, by a progres- 
sive forward bending or lordosis of the flexible lumbar spine below 
the projection. One must guard against this by applying the jacket 
firmly while the spine is made as straight as possible, or if the brace 
is used, the lumbar spine should be drawn firmly against it. 

If lateral inclination of the body is so marked as to interfere with 
the proper application of a brace, preliminary rest in bed is indicated. 
Lateral deviation can be corrected as a rule by the jacket without re- 



SPECIAL INDICATIONS FOR TREATMENT. 85 

cumbency, although this, as other forms of symptomatic distortion, 
should be treated ordinarily, if not by complete rest, at least by care- 
ful regulation of the period of activity. 

Disease of the Middle and Upper Dorsal Region. — This is, from 
the standpoint of prevention of deformity, the most difficult region of 
the spine to treat, although the symptoms of the disease may be easily 
relieved. 

Deformity is present in nearly all cases when treatment is sought, 
and, deformity having begun, is very difficult to check, for the reasons 
that have been already stated. 

The final result in the majority of cases is what appears to be ex- 
aggerated round shoulders ; the neck is shortened and projects forward, 
the chest is flat and the shoulders are high. 

It is only by an early diagnosis and by efficient and long continued 
treatment that recovery from disease in this region without noticeable 
deformity, may be hoped for. 

In all cases of disease above the ninth vertebra, the anterior brace 
for backward traction of the shoulders may be used with great advan- 
tage to secure greater fixation of the spine ; and in all cases above the 
seventh or eighth vertebra a head or chin support to restrain the for- 
ward inclination of the neck is indicated in addition. 

With the plaster jacket the jury mast is employed, with the brace 
the looped chin rest or the ordinary Taylor support may be used. 

In disease of the middle and upper dorsal region the brace is to 
be preferred to the jacket because of the greater accuracy of adjust- 
ment, and because the halter of the jury mast is rarely retained in 
proper position when the patient does not, as in these cases, feel the 
need of such support. 

In this region of the spine, paralysis frequently occurs as a compli- 
cation. When it appears after treatment is begun, it is usually a result 
of inefficient fixation of the spine or of want of caution in regulating 
the strain to which the diseased part is subjected. Its symptoms 
and its treatment will be considered later. 

Disease of the Upper Dorsal and Middle Cervical Region. — This is the 
most favorable region of the spine for treatment. The disease is 
usually not extensive because of the small size and compact structure 
of the vertebra? ; and the mobility of the cervical region is so great 
that it readily compensates for the local rigidity. 

Under efficient treatment one may predict recovery without notice- 
able deformity and in the less successful cases the deformity is not, as 
a rule, offensive. The shoulders appear high, the neck is short, the 
head inclines forward while the back is abnormally flat in compensa- 
tion for the change in contour of the part above. 

When the case of cervical disease is first brought for treatment, a 
wry neck deformity, often made more persistent by the infiltration of 
an abscess or by inflamed cervical glands is almost always present. 
As a means of correcting this distortion, the jury mast and traction 
halter, attached to the jacket or brace is a very efficient and comfortable 



86 TUBERCULOUS DISEASE OF THE SPINE. 

support. Under the constant tension the deformity is, as a rule, very 
quickly corrected, but as a permanent treatment, the brace and head 
support are to be preferred to the jury mast, because a more exact fixa- 
tion is assured ; for, as has been stated, although the jury mast, when 
properly applied and adjusted, is an admirable support, yet under other 
conditions it is absolutely worthless. 

The distortion of the head may be overcome also by traction in bed, 
and it will usually disappear under simple fixation. The use of col- 
lars of felt or leather has been mentioned. With the brace these are 
unnecessary, but they may be used with advantage to add to the effi- 
ciency of the plaster jacket and jury mast. 

Disease of the Occipito-Axoid Region. — Under efficient treatment the 
prognosis is good, and recovery without deformity should be the rule. 
The course of the disease, although it is often accompanied by acute 
symptoms, is usually short as compared with that of other regions of the 
spine ; and it may be assumed that, in many cases, it is a primary 
arthritis, or at least that the primary focus in the atlas or axis is very 
small. The disease at this point is however in close proximity to the 
vital centers, and sudden death from displacement of the weakened 
parts is not uncommon. Abscess is frequent and it is often a trouble- 
some and dangerous complication. 

As has been mentioned, wry neck deformity is a very constant 
symptom, and there is also a strong tendency toward a forward and 
downward inclination of the head, so that in neglected cases the chin 
may rest upon the chest. The indications for treatment are to over- 
come the distortion and to hold the head fixed in the middle line, the 
chin being somewhat elevated above the right-angled relation with the 
spine. In the mild cases the jacket-and-jury-mast traction may be 
used to overcome the distortion, but the metallic head support with the 
fixation attachment, to prevent motion in the diseased joints, is always 
indicated as the treatment of selection because by such apparatus the 
danger of displacement may be avoided. 

When the disease is acute in character, and especially if abscess be 
present, recumbency on the frame with fixation of the head and slight 
traction by the weight and pulley, or by the jury mast attachment, is 
indicated. Traction should not be sufficient to cause discomfort ; 
counter traction may be supplied by the weight of the body and by 
slight elevation of the head of the bed. The head sling is of the form 
used with the jury mast, or a simple band about the head may be 
used. Under this treatment slight deformity of any part of the cer- 
vical region will practically disappear, and as a rule the course of the 
disease is very favorably influenced by it. 

In certain cases of disease of this region, accompanied by acute 
symptoms, the attitude of recumbency is extremely uncomfortable. 
The discomfort is caused apparently by the forward projection of the 
upper part of the spine, so that when the head is drawn upward and 
backward in the recumbent attitude the calibre of the throat is lessened. 
In other instances the pain may be due to pressure of the atlas against 



THE COMPLICATIONS OF POTTS DISEASE. 87 

the odontoid process of the axis. In such cases, if recumbency is 
desired, the head must be elevated by pillows to the point of comfort, 
the support being removed when the child has become accustomed to 
the position, or when the deformity has been corrected. 

The Complications of Pott's Disease. 

Abscess. — It may be assumed that a limited collection of tuberculous 
fluid is present at some time during the course of Pott's disease in the 
great majority of cases, but unless it appears as a palpable tumor above 
or below the thorax or upon the surface of the body its presence is not 
often detected. 

Townsend, 1 in 380 cases of Pott's disease examined with reference 
to the occurrence of abscess as a complication, found that it was pres- 
ent or had been detected in 75 (19.7 per cent.), in 8 per cent, of the 
cases of cervical disease, in 20 per cent, of the dorsal and in 72 per 
cent, of those in which the lumbar region was involved. 

Dollinger, 2 in 700 cases under treatment from 1883 to 1895 found 
abscess in 154 (22 per cent.) ; in 13 of 63 cases in the cervical region 
(22.6 per cent.) ; in 47 of 403 cases in the thoracic region (11.6 per 
cent.) and in 94 of 234 cases of lumbar disease (40.17 per cent.). 

Ketch, 3 in 75 cured cases of Pott's disease treated at the N. Y. 
Orthopaedic Dispensary, selected for the purpose of contrasting the be- 
havior of the disease in the different regions of the spine found that 
abscess had appeared in 19 (25.3 per cent.). In the upper region 
abscess was detected in but one of the 25 cases (4 per cent.) ; in the 
middle region in 8 of the 25 cases (32 per cent.) and in the lower 
in 10 (40 per cent.). 

In 354 autopsies by Mohr, Nebel Bouvier and Lannelongue abscess 
was found in 281 or nearly 80 per cent. Although cases of Pott's 
disease that come to autopsy may be supposed to represent a severe 
type of disease yet it is evident, by contrasting the statistics, .that a 
large proportion of the abscesses escape detection in the living. One 
may conclude then, that abscess may be expected as a more or less 
serious complication in 25 per cent, of all cases of Pott's disease, and 
in at least half of those in which the lower region of the spine is in- 
volved, the greater frequency here, being explained by the large size 
and less resistant structure of the vertebral bodies, as compared with 
those of the upper regions. 

The tuberculous abscess is separated from the neighboring parts by 
a limiting wall of more or less thickness, according to its age, the 
outer layers of which are of fibrous and cellular tissue, the inner of 
granulation tissue covered with yellowish-gray or pinkish-gray necrotic 
membrane which is easily separated from the underlying parts. The 
fluid of the abscess is of a whitish or whey-like color composed of 

1 Trans. Am. Ortho. Ass'n, Vol. IV., p. 166. 

2 Dollinger, loc. cit. 

3 Trans. Am. Ortho. Ass'n, Vol. IV., p. 200. 



88 TUBERCULOUS DISEASE OF THE SPINE. 

serum, leucocytes and emulsified caseous material and fibrin ; floating in 
it are larger masses of cheesy necrotic tissue and sometimes minute 
fragments of bone. This more solid material settles to the bottom of 
the glass if the fluid is allowed to stand. The fluid of quiescent ab- 
scesses or those that are in process of resolution is often clear, like 
serum, but if secondary infection has taken place the pus is of a 
greenish-yellow color, and is of uniform consistency. At any stage of 
its progress the abscess may become stationary and its contents may 
be absorbed, in fact such an outcome is not unusual ; the fluid of the 
abscess is usually sterile and secondary infection, before a communica- 
tion with the exterior of the body is established, is comparatively rare. 

It has been claimed that abscess formation is always the result of 
infection with pyogenic germs, but this may be doubted, since the 
ordinary tuberculous abscess may be sterile or at most contain but a 
few tubercle bacilli. It is very certain, however, that the formation 
and increase of the abscess is favored by irritation and injury, and 
that the most eifective treatment of this complication is to support the 
diseased spine and to relieve it from over-strain. 

Abscess is a symptom of disease and is, in some degree, an evidence 
of its character. If it appears early and increases in size rapidly, it 
usually indicates a destructive and rapidly advancing process, or infec- 
tion from without. On the other hand, the slowly enlarging or quies- 
cent abscess has but little significance. 

In many instances the abscess causes no symptoms whatever, or it 
may be a source of inconvenience simply because of its size or situa- 
tion. In other cases, a period of malaise or discomfort or pain is fol- 
lowed and explained by the appearance of an abscess, but whether the 
symptoms were caused by the tension of the abscess or by a more acute 
phase of the disease itself, is not always clear. 

Large abscesses, which are increasing in size and approaching the 
surface are usually accompanied by pain, and by elevation of temper- 
ature, that indicates probably a slight degree of secondary infection, 
but otherwise the ordinary deep abscess appears to have no other ef- 
fect than to add, doubtless, to the susceptibility of the patient. 

The Course and Peculiarities of Abscess in the Different Regions of the 
Spine. — The tuberculous abscess may remain as a small collection of 
fluid in the neighborhood of the disease where its presence may be de- 
tected only by percussion or by deep palpation. As a rule, however, 
it slowly increases in size, and under the influences of the force of 
gravity and the tension of its contents it finds its way down the spine 
or toward the exterior of the body, following the path of least resistance. 
The abscesses which have passed below the diaphragm or which have 
originated below this point may follow various paths. Some enter the 
sheath of the psoas muscle and finally make their appearance on the 
inner aspect of the thigh, psoas abscess. Others perforate the sheath 
of the quadra tus lumborum muscle and form a lumbar abscess projecting 
between the twelfth rib and the crest of the ilium at the triangle of 
Petit. Those abscesses that escape from the fascia of the psoas muscle 



THE COMPLICATIONS OF POTTS DISEASE. 



89 



or that pass downward on the surface of the iliac fascia, the so-called 
iliac abscesses, often form a tumor over the outer extremity of Pou- 
part's ligament at the junction of the transversalis and iliac fasciae, or 
the fluid may follow the course of the iliac artery to the thigh, or, 
escaping from the greater sacro-sciatic foramen, form a gluteal abscess. 

Iliac or psoas abscess is most often confined to one side but it 
may be bilateral, the two sacs communicating with one another by a 
larger or smaller channel. In the thoracic region the abscess may re- 
main indefinitely in the posterior mediastinum, where, if large, its 
presence may be demonstrated by an area of dullness extending toward 
the lateral region of the thorax 

or it may perforate the inter- Fig. 56. 

costal muscles and appear on 
the posterior or lateral aspect 
of the chest, or it may pass 
downward through the aortic 
opening in the diaphragm and 
become an iliac abscess. 

Abscess caused by disease of 
the occipito-axoid region may 
force its way forward between 
the recti muscles and appear 
behind the pharynx as the 
retro-pharyngeal abscess, or the 
fluid may take the opposite di- 
rection and distend the sub- 
occipital triangle and then pass 
forward to the region of the 
mastoid process. In other in- 
stances the abscess may dissect 
its way about the base of the 
skull or pass upwards through 
the foramen magnum or down- 
ward into the spinal canal. 

Abscesses from the middle 
cervical region usually pass out- 
ward between the scaleni and 
longus colli muscles to the inter- 
val between the trapezius and sterno-mastoid, perforating the skin 
about the middle of the lateral aspect of the neck near the anterior 
border of the latter muscle. 

These are the paths usually followed by the tuberculous fluid, but 
occasionally it may enter the spinal canal or break into the pleural 
cavity or lung or intestine or by the side of the rectum or elsewhere. 

Treatment of Abscess. — Abscess is by far the most troublesome and 
dangerous complication of Pott's disease. It may interfere with proper 
mechanical treatment, and it is often a cause of permanent as well as 
temporary deformity, especially in the lower region of the spine as 




Bilateral lumbar abscess. 



90 TUBERCULOUS DISEASE OF THE SPINE. 

has been stated. It prolongs the course of the disease by extending 
its boundaries and although it is not often a direct cause of death, yet 
many patients die because of the exhaustion of long-continued suppura- 
tion that may follow secondary infection and of the amyloid degenera- 
tion that may finally result. 

A large abscess is always a source of danger because of the possi- 
bility of secondary infection of its contents before it finds an outlet 
and because of the probability of infection, when a communication 
with the exterior has been established. Abscess is however a symptom 
and result of disease and in properly treated cases it is as a rule a 
complication of comparatively slight consequence. If abscess is not 
present when treatment is begun, one may hope to prevent it by effec- 
tive protection of the spine, and if it be present, this protection should 
be all the more rigidly enforced. 

The surgical treatment of the abscess of spinal disease is very diffi- 
cult, not because it is different in character from other tuberculous ab- 
scesses, but because it is as a rule impossible to remove the disease of 
which the abscess is a symptom ; and incomplete or ineffective surgi- 
cal operations should be avoided. 

As the abscess is a symptom of disease so, as a rule, its treatment 
should be symptomatic. The retro-pharyngeal abscess demands prompt 
evacuation because it is likely to obstruct breathing and swallowing, 
because its sudden rupture may cause death and because an abscess in 
such close proximity to the vital centers is always a source of danger. 
In cases of emergency the abscess may be evacuated by an incision in 
the middle line of the pharynx, but preferably the opening should be 
from the exterior. An incision is made along the posterior aspect of 
the sterno-mastoid muscle in its upper third. The abscess tumor is 
easily reached by careful dissection and drainage is established which 
has evident advantages over that into the throat. 

Abscesses from the middle cervical region usually point in the lat- 
eral region of the neck and cause but little inconvenience. Abscesses 
in the upper thoracic region may, in rare instances, cause dangerous 
pressure on the trachea or lungs as shown by spasmodic attacks of in- 
spiratory dyspnoea, " asthmatic attacks." In some instances an area 
of dullness near the seat of disease demonstrates the position of the 
abscess, but if it lies in the median line it can not be detected either 
by auscultation or percussion. If the inspiratory dyspnoea is well 
marked the symptom may be fairly attributed to this cause and the 
operation of costo-transversectomy may be undertaken to relieve the 
pressure. An incision is made, preferably on the right side, to expose 
the articulation between the transverse process and the rib ; the joint 
may be resected or a section from one or more of the ribs may be re- 
moved as in the operation for einpysema ; the finger is then inserted 
and passed along the surface of the adjacent vertebral body until the 
abscess sac is reached. It is then opened and drained. (Fig. 9.) 

In the lower region of the spine operations may be necessary be- 
cause there is evidence of secondary infection. In this event if the 



THE COMPLICATIONS OF POTT 1 S DISEASE. 91 

abscess distends the lumbar region or forms a sac on either side of 
the spine, an opening in the loin on one or both sides of the spine is 
necessary. This is made as in operations on the kidney, by an incision 
on the outer side of the erector spinse muscle between the last rib and 
the crest of the ilium ; the underlying quadratus lumborum muscle is 
out through transversely and the abscess cavity is entered. In certain 
cases, it is possible to expose the spine and to remove fragments of 
necrosed bone along with the contents of the abscess. As a rule the 
complete removal of the lining membrane of the abscess is not pos- 
sible, and one must be content to evacuate the solid and semi-solid 
contents by flushing with hot water, together with as much of the 
abscess membrane as may be removed by swabbing with gauze. The 
most important point in the operation is to provide for efficient and 
complete drainage of the cavity ; if this is assured there is little 
danger to be apprehended from subsequent infection. Two or more 
counter openings are usually necessary when the lumbar incision has 
been made, one just in front of the anterior superior spine and another 
in the thigh, if the abscess is of the psoas variety. Long drainage 
tubes are inserted and should remain until a proper channel for the 
escape of pus has been established. 

When the abscess is of one side only, not extending into the thigh, 
and when the symptoms do not indicate infection, but when its evacu- 
ation seems advisable because of its size and tension, it may be opened 
by an anterior incision below Poupart's ligament just to the inner side 
of the sartorius muscle. After copious injections of hot water a drain- 
age tube may be inserted long enough to reach to the seat of disease if 
it be of the lumbar region. 

In after-treatment irrigation is not often required ; the dressing 
should be of dry sterile gauze and great attention should be paid to 
absolute cleanliness and to effective drainage. As soon as is possible, 
if the discharge has become slight and if the back can be properly 
supported, the patient is allowed to walk about and to go into the open 
air. In ordinary cases a slight discharge will persist for' several 
months or longer, depending on the condition of the disease ; if how- 
ever it be quiescent or cured the sinus will promptly close. 

In the symptomatic treatment of abscess, aspiration is sometimes of 
service, for by this means it may be prevented from increasing in size ; 
and when the disease is quiescent, the cure of the abscess may follow 
the removal of its contents which allows the collapse of its walls. 
When aspiration is employed it should be repeated systematically as 
often as the abscess cavity refills. After each evacuation pressure 
should be applied to favor the adhesion of the apposed walls. 

When the contents are of such a nature that aspiration is impracti- 
cable, an incision may be made, through which the semi-solid substance 
may be removed by vigorous flushing with hot water. The opening 
is then closed and pressure is applied with the aim of obtaining pri- 
mary union. This method is sometimes successful, but usually a sinus 
forms later at the point of incision. 



92 TUBERCULOUS DISEASE OF THE SPINE. 

Until recently the injection of anti-tuberculous remedies into the ab- 
scess sac was in favor. This is probably of value in diminishing 
the infective quality of the contents, perhaps also, in lessening the 
danger of mixed infection and in stimulating absorption, although it 
appears to have little direct effect upon the course of the tubercu- 
lous process. An emulsion of iodoform in sterilized oil or glycerine, 
10-20 per cent, in doses of from 4-30 grammes is injected at intervals 
of from two to four weeks, with or without previous evacuation of the 
contents ; the amount and the frequency of the injection depending 
upon the age of the patient and upon the effect of the treatment. If 
used with caution as to asepsis, and to the toleration of the patient for 
iodoform, no harm will follow, even if the treatment proves to be of 
little practical value. 

When an abscess approaches the surface, the skin becomes red and 
thin and there is usually some local tenderness and pain. Whenever 
spontaneous evacuation of the abscess is probable, the mother should 
be instructed as to the necessity of absolute cleanliness, and the proper 
dressings should be provided. After the abscess has broken, the patient 
should remain in bed for several days, or until the discharge has be- 
come small in amount. 

In the symptomatic treatment of the abscesses of Pott's disease, we 
may conclude then that operation will be indicated in the treatment of 
the retro-pharyngeal abscess and in the rare instances when dangerous 
pressure is exerted by an abscess in the posterior mediastinum. It is 
indicated of course when there is evidence of mixed infection or when 
the rapidly increasing abscess causes discomfort, or interferes with ef- 
fective support. It is usually indicated when the abscess is of large 
size if proper care can be provided. The operative treatment is practi- 
cally free from danger if cleanliness and efficient drainage can be assured. 
Aspiration is practically free from danger and is often of service in pre- 
venting the enlargement of the abscess and it may hasten its absorption. 

While the operative treatment of large abscesses is, under proper 
conditions, free from danger and is likely to become the treatment of 
selection and routine in those cases for which efficient after-treatment 
can be provided, yet in the majority of cases the symptomatic treat- 
ment that has been outlined is likely to hold a permanent place, since 
in large cities there are far more patients who have abscesses than 
there are hospital beds to put them in. Treatment under such limita- 
tions has demonstrated the fact that the abscess is of little consequence 
when the primary disease has been properly treated. An abscess often 
exists for months before its presence is detected and after its discovery 
it may remain quiescent for a long time and finally disappear. 

A very large proportion of the abscesses of Pott's disease cause no 
symptoms, but slowly find their way to the surface of the body. Mean- 
while it may be assumed that the disease of the spine, of which the ab- 
scess is a result, is in process of cure ; so that when the fluid finds an 
outlet, the source of supply will be shut off and permanent closure of 
the sinus may follow. 



FREQUENCY OF PARALYSIS. 93 

Finally a discharging sinus communicating with the interior of the 
body, whether it be the result of an operation or not, is always a 
source of discomfort. It may interfere with effective support, and if 
the discharge is large in amount it is much more serious in its effect 
upon the patient than was the abscess when it was contained in the 
interior of the body. 

These are practical arguments that are particularly effective when 
contrasted with the evidence in favor of the so-called radical treatment 
that consists in the evacuation of every collection of fluid because it 
is an abscess, without regard to the general condition of the patient or 
to the local disease of the bone of which it is a complication. 

Paralysis from Pott's Disease. 

The tuberculous process in the vertebral bodies may extend back- 
ward and breaking through the posterior ligament it may enter the 
epidural space and press upon the spinal cord ; then follows paresis or 
paralysis of the parts below the constriction. In rare instances the 
pressure may be due to a fragment of necrosed bone. Not infrequently 
it is caused in part at least by the pressure of a neighboring abscess, 
but it is usually the result of the slow advance of the tuberculous 
granulation tissue. When this has forced an entrance into the spinal 
canal it sets up a resistant inflammatory thickening of the coverings 
of the cord, first a peripachymeningitis and then a pachymeningitis, 
so that in addition to the direct pressure there may be an interference 
with the blood supply and with the lymphatic circulation. Thus local 
oedema of the cord may follow and as a later result an increase in the 
interstitial connective tissue of its substance with a corresponding 
atrophy of the nervous elements ; an ascending and descending de- 
generation that, in prolonged cases, may terminate in partial or com- 
plete sclerosis. The dura mater is a resistant structure and direct 
destruction of the cord by the tuberculous disease is rare. In fact, as 
a rule but little permanent damage results even from long-continued 
pressure and paralysis, for the cord seems in these cases to possess the 
power of repair and regeneration to a remarkable degree. 

The calibre of the spinal canal is not usually lessened by the char- 
acteristic angular distortion of the back, although the weight and for- 
ward inclination of the trunk may force the softened tissues backward 
against the cord and thus increase the direct pressure ; in fact paralysis 
is much more often associated with a slight or moderate kyphosis than 
with extreme deformity. 

Frequency of Paralysis. — In 1,670 cases of Pott's disease recorded 
at the New York Orthopaedic Dispensary, paralysis occurred in 218, 1 
and in 445 cases in the private practice of Dr. C. F. Taylor, 2 59 cases 
of paralysis were observed. Thus in a total of 2,015 cases of Pott's 
disease there were 279 cases of paralysis or 13.7 per cent. 

1 Myers, Trans. Am. Ortho. Ass'n, Vol. III., 1891, p. 209. 

2 Taylor and Lovett, N. Y. Med. Kecord, June 19, 1896. 



94 TUBERCULOUS DISEASE OF THE SPINE. 

This proportion is much larger than the normal however, for many 
of the patients were taken to the specialist or to the special hospital 
because of the paralysis, as in 40 of Taylor's and in 133 of the Dis- 
pensary cases. If these be excluded, the percentage of paralysis oc- 
curring in those actually under treatment is reduced to 5.6 per cent. 
This percentage corresponds very closely to that of Dollinger, 1 viz.: 
41 cases of paralysis in 700 cases of Pott's disease under treatment 
(5.8 per cent.), and it may be accepted as representing the average 
liability to paralysis among those who have received treatment for 
Pott's disease, the percentage being much higher in neglected cases. 

The Liability to Paralysis in Disease of the Different Regions 
of the Spine. — The liability to paralysis is very much greater in dis- 
ease of certain regions of the spine than in others. 

Thus 105 of the 209 cases in Myers's list, in which the situation of 
the disease was recorded, complicated disease of the dorsal region above 

Fig. 57. 




Pott's paraplegia before the stage of deformity. The same patient is shown in Fig. 47. 

the eighth vertebra. Of the remainder, in 16 the disease was of the 
cervical region ; in 12 of the cervico-dorsal and in 59 of the lower 
dorsal and dorso-lumbar regions. 

37 of Taylor's 59 cases were caused by disease of the dorsal region ; 
8 occurred in the cervical and cervico-dorsal, and 11 in the dorso- 
lumbar and lumbar regions. 

26 of the total of 41 cases recorded by Dollinger were caused by 
disease of the third to the seventh dorsal vertebra? inclusive, or about 
23 per cent, of the cases in which this region was involved. 

In 132 cases of paraplegia reported by Gibney, 2 not one complicated 
disease of the lumbar region ; nearly all were caused by compression 
in the middle or upper dorsal segment. 

These statistics show that the upper and middle dorsal section is 
the point of greatest liability to paralysis, a fact that is explained 
possibly by the smaller size of the canal at this point, and by the dif- 
ficulty in assuring complete fixation at the seat of disease. In this 

1 Loc. cit. 

2 Journal of Nervous and Mental Diseases, Jan. 5, 1897 



SYMPTOMS OF POTT'S PARAPLEGIA. 95 

region it may be estimated that 15 per cent, of the cases of Pott's dis- 
ease will be complicated by paralysis before cure is established. 

Prognosis. — In properly treated cases the prognosis is very favor- 
able. The final results of 47 of the 59 cases of paraplegia in Taylor's 
practice were ascertained. Of these 39 recovered completely, 5 died of 
intercurrent disease while apparently recovering and in 3 the recovery 
was partial. 

Of the hospital cases recorded by Myers, 3 per cent, died of inter- 
current disease. The final results could be ascertained in but 55 per 
cent, of the patients who remained under treatment. All of these re- 
covered. 

In 74 cases of paraplegia treated by Gibney, 1 45 were cured, 12 
improved, 8 unimproved and 9 died. Thus 77 per cent, were cured 
or improved ; and in a similar series of 40 cases reported by Shaffer 
80 per cent, were cured and but 10 per cent, of the remainder were 
considered as hopeless cases. 

Recurrence of paralysis after recovery is not infrequent ; in 18 cases 
such recurrences from one to four times are recorded by Myers, and 
seven successive attacks of paralysis were observed in a patient under 
treatment at the Hospital for Ruptured and Crippled. 

The relapses depend upon the situation or upon the renewed activ- 
ity of the disease and are often explained by the neglect of protective 
treatment. 

Duration. — In exceptional cases the paralysis appears to be caused 
by temporary pressure or simply to disturbance of the circulation of 
the cord, due possibly to the pressure of the superincumbent weight 
upon the softened and diseased tissues, as it disappears almost immedi- 
ately when the spine is straightened and supported. Usually the par- 
alysis remains for several months, not infrequently it lasts a year, and 
partial or even complete recovery is possible after a much longer time. 
Recovery from the paralysis depends upon the course of the disease of 
which it is a symptom, upon the absorption and organization of the 
tuberculous granulations that press upon the cord and upon the regen- 
erative changes in its structure, if it has been implicated in the disease. 

Time of Onset. — In exceptional cases the paralysis may precede de- 
formity and it may be the first symptom that attracts attention to the 
disease. In 14 of 74 cases reported by Gibney, the paralysis was 
present when the bone disease was recognized, but it is probable that 
the primary disease had existed for several months before the appear- 
ance of the paralysis. Usually it is a comparatively late symptom, 
appearing after the stage of deformity and more often from 6 to 12 
months after the recognition of the disease, but its appearance may be 
deferred until long after apparent cure. 

Symptoms of Pott's Paraplegia. — The most marked effect of the 
pressure on the cord is the interference with its conductivity ; thus the 
reflex centers situated below the point of constriction, relieved from 
the inhibition of the brain, become over-active, while voluntary mo- 
tion of the parts below the constriction is difficult or impossible. 

1 Loc. cit. 



96 TUBERCULOUS DISEASE OF THE SPINE. 

The pressure of the diseased products is more directly upon the 
antero-lateral columns so that motion is much more often primarily 
affected than is sensation. 

The early symptoms of Pott's paraplegia, as noticed by the patient or 
his friends, are weakness, awkwardness and a stumbling, shambling gait. 
The symptoms usually increase rapidly until paralysis of motion is com- 
plete. At this stage the patella tendon reflex is increased and ankle 
clonus is often present. As a rule both legs are affected in equal degree, 
but occasionally paralysis of one leg may precede that in the other; or 
in the stage of recovery power may return more rapidly in one limb 
than in the other. The limbs in the early stage of the paralysis may 
appear limp and powerless, but when the patient is moved or when the 
reflexes are stimulated the peculiar spastic rigidity or stiffness appears. 

As a rule the rigidity increases with the duration of the disease and 
spastic contractions are often present ; thus the thighs may be approx- 
imated, the knees flexed and the feet extended. Persistent contrac- 
tions indicate, as a rule, permanent damage to the cord, and at this 
stage complete recovery is infrequent. 

Sensation is retained in the mild cases, but in the more severe or 
prolonged cases it may be impaired or lost. Sensation was retained 
throughout in 24 of the 40 cases reported by Shaffer. 

In the cases of partial paralysis, control of the bladder may be re- 
tained, but usually there is incontinence. As the bladder fills the 
reflex center is excited and it empties itself. The control of the 
sphincter ani is less often or less noticeably affected. 

As the paralysis is the result of more active or of advancing disease, 
its onset may be preceded by an increase of pain ; thus greater dis- 
comfort attended by an increase in the patella tendon reflex may be 
considered as an indication for enforced rest of the individual, although 
increased activity of the reflexes is not uncommon during the more 
active stage of the disease without apparent involvement of the spinal 
cord. When paralysis occurs in patients who are under treatment for 
Pott's disease the onset is not, as a rule, attended by noticeable or un- 
usual pain, the reflected pain or nerve root symptoms, so often de- 
scribed, do not differ from the ordinary pain of Pott's disease ; in 
many cases such symptoms are lacking, nor is pain usually complained 
of after the paralysis has developed. 

The extent of the paralysis depends upon the situation of the disease. 
In exceptional cases, when the cervical cord is implicated, both the 
arms and legs may be paralyzed ; this occurred in seven of the cases 
reported by Myers. As a rule, however, the paralysis is a complica- 
tion of disease of the dorsal region, above the reflex centers in the 
lumbar enlargement of the cord, but below the nerve supply of the 
upper extremities. If the disease were at a lower point, for example 
in the dorso-lumbar section, so that these reflex centers themselves 
were directly implicated, then reflex activity would not be increased, 
and intermittent incontinence would be replaced by constant dribbling 
of urine ; or if the cauda equina alone were implicated in disease of 



TREATMENT. 97 

the lumbosacral region, the symptoms would be those of neuritis, pain, 
numbness and weakness in the area supplied by the affected nerves. 

In ordinary cases, the nutrition of the limbs is not greatly affected, 
nor do the contractions become permanent, but when the paralysis is 
prolonged, and when sensation is lost, the muscles waste, the circula- 
tion is impaired, and fixed distortions usually appear. But even in 
the more prolonged and severe forms of paralysis, occurring in child- 
hood, bedsores are rarely seen. 

Treatment. — The treatment of the paralysis is included in the 
treatment of the disease of which it is a symptom, except that even 
greater care should be exercised to assure fixation of the spine. 

Rest in the horizontal position on the Bradford frame is indicated, 
and over-extension of the spine should be aimed at by bending the 
side bars in the manner described. Direct traction by the weight and 
pulley should be used if the disease is in the upper dorsal or cervi- 
cal regions. The back brace, in addition to the frame, assures addi- 
tional fixation, and should be used if possible. If, however, the brace 
has been worn before the paralysis, its shape must be modified to ac- 
commodate the change in the outline of the spine, induced by recum- 
bency and extension. 

Manipulation or massage of the limbs is contraindicated because it 
stimulates the reflex centers. If constant contractions of the muscles are 
present, the deformity may be reduced by traction applied in the ordi- 
nary manner (Fig. 28), or a fixation brace may be worn. The spasmodic 
contractions are often painful, and if the paralysis is complicated by 
tuberculous joint disease, extension and fixation combined may be 
indicated to relieve the joint from the injury of involuntary motion. 

Counter-irritation at the seat of disease was by Pott considered of 
the greatest value, and the application of the actual cautery from time 
to time, about the kyphosis, seems in certain cases to exert a favorable 
influence on the underlying disease. 

Electricity, particularly galvinism, has been used and it is qf some 
service in preserving the nutrition of the limbs. Its value in a case 
must be judged by its effect. 

Of the internal remedies the most useful seems to be iodide of potas- 
sium. It is supposed to act upon the tuberculous granulation tissue 
as upon the products of syphilitic disease. A convenient method of 
administration is a solution of which one drop represents one grain of 
the drug. This is given in milk or in Vichy water beginning with 
five drops three times daily and increasing the dose a drop each day 
until the point of toleration is reached. 

The first indication of improvement is usually lessening of the 
muscular rigidity ; then the ability to move a toe is regained, after 
which recovery follows quickly. At this stage massage of the limbs 
may be employed with advantage. The exaggerated reflexes may per- 
sist long after recovery, in fact, as has been stated, this symptom is not 
uncommon among patients suffering from dorsal Pott's disease who 
have never been paralyzed. 
7 ■ 



98 TUBERCULOUS DISEASE OF THE SPINE. 

The Operative Treatment. — The operation of laminectomy was at 
one time in favor but it has now been practically abandoned, as a 
treatment of routine at least, for the paraplegia of Pott's disease ; be- 
cause it has been proved that recovery, if somewhat long deferred, is 
the rule without operation while the direct death rate of the operation 
is at least 20 per cent. In 134 cases collected by Rhein l the imme- 
diate mortality (those dying within a month after the operation) was 
36 per cent. 

Laminectomy is an incomplete operation in the sense that the dis- 
ease of the bone is not removed, and recurrence of paralysis and ex- 
tension of the disease are not infrequent after a successful immediate 
result. It should be reserved for those cases in which after a thorough 
and prolonged trial of ordinary methods the condition does not im- 
prove. Eighteen months has been suggested as the proper time in which 
to test conservative treatment. The operation may be indicated also 
if the symptoms, in spite of treatment, increase in severity, and when 
there is evidence that the integrity of the cord is threatened, or when the 
paralysis is of sudden onset, or when displacement of bone or pressure 
from an abscess seems probable as the exciting cause although in the 
latter instance the direct evacuation of the abscess by costo-transver- 
sectomy, as advocated by Menard, would seem to be the more reason- 
able procedure. Occasionally the operation is performed as a forlorn 
hope in adults suffering from cystitis and bedsores. 

The usual method in operating is as follows : A long incision is 
made parallel to and close by the side of the spinous processes. The 
muscles are drawn to one side, the spinous processes are cut through 
and drawn with the attached muscles to the opposite side. The lam- 
inae at the seat of disease are then removed with the cutting forceps, 
exposing the dura mater. The tuberculous tissue is usually found upon 
the front or lateral surfaces of the canal, and its complete removal is 
often impossible. The shock of the operation is often marked so that 
it should be as rapid as possible, and loss of blood should be carefully 
guarded against. After the operation the spine should be supported 
by the brace or jacket until the disease is cured. 

In several instances forcible correction of the spine (Calot's opera- 
tion) relieved the pressure on the cord and rapid recovery followed. 
This indicates the importance of assuring over-extension of the spine 
whenever it is possible, but this should be attained by gradual, postural 
correction rather than by force. 

Fortunately the great majority of cases of paraplegia from Pott's 
disease occur in childhood, and, as has been mentioned, the complica- 
tions of later life, bedsores, cystitis and the like, are rarely trouble- 
some. Such paralysis in the adult is more serious from every point of 
view. The principles of treatment are the same, but their application 
is more difficult and the prognosis is more doubtful. 

Local Paralysis. — In certain cases the extension of the disease may 
involve the nerve roots at their exit from the spine. This may occur 

1 Willard, Journal of Nervous and Mental Diseases, May, 1897. 



DURATION OF TREATMENT OF POTTS DISEASE. 99 

with, or independently of, the involvement of the cord. The symp- 
toms are those of neuritis in the affected nerves. In extremely rare 
instances the pressure on the cord may cause hemiplegia. 

The Duration of the Treatment of Pott's Disease. — The duration 
of the treatment must depend upon the extent and severity of the disease. 
It may be divided into two stages : one during which the disease is 
active, when absolute fixation is indicated, and a stage of recovery, 
during which supervision is required. During the first stage the de- 
structive process may increase the absolute deformity ; during the later 
period of weakness the distortion may increase, simply because of the 
general inclination toward deformity and because of the weakness of 
the supporting muscles. 

Tuberculosis of the spine is slow in its progress and recovery is 
often insecure. The course of the disease is shortest in the cervical 
region, but even here two years of brace treatment will probably be 
required, and in the lower region double this time, even in the milder 
type of cases. Active treatment should be continued as long as there 
is evidence of disease. The absence of the general symptoms of pain and 
weakness is of little value in determining the absolute cure if braces 
have been employed. Muscular spasm is of more value, since it usually 
persists as long as the disease is active ; the presence of pain on pas- 
sive motion or muscular contraction or abscess would of course indicate 
the necessity of further treatment. 

Direct palpation is of some value in determining the condition of 
the affected part. During the progressive stage careful, deep pressure 
over the spinous processes may show greater mobility of those involved 
in the disease. During the stage of repair and consolidation the mobil- 
ity is replaced by rigidity. The appearance of the kyphosis has also 
some significance. In the early stage of the disease its area is not 
clearly defined, but when consolidation has taken place the extent of 
the disease is shown by the rigid vertebrae which stand out separated 
from the remainder of the spine by a well-marked sulcus which is 
much deeper below than above the kyphosis. 

Even when the disease appears to be cured, removal of support 
should be gradual and tentative ; the jacket is replaced by the corset, 
the brace by a lighter appliance, then support is removed at night, 
later for part of the day and at last, after many months, it is discarded. 
Such careful supervision must be continued for a much longer time 
if the best ultimate result is to be attained, for as has been mentioned, 
one should guard against the secondary distortions, which may be due 
simply to weakness and to the unfavorable mechanical conditions in- 
duced by the primary deformity. If curvatures of the spine are so 
common among those whose backs may be supposed to be fairly normal, 
how much more likely is such secondary deformity to result when the 
back has been weakened by disease and by long disuse of the muscles. 
This secondary increase of deformity is not so much to be feared 
after the cure of the disease in the lumbar region, because of the favor- 
able attitude of erectness, nor is it likely to be marked after cure in 

LrfC. 



100 TUBERCULOUS DISEASE OF THE SPINE. 

the cervical region of the spine ; but in disease of the upper and mid- 
dle dorsal region brace treatment must be continued long after the 
disease is cured, and supervision must be exercised until after the period 
of adolescence, if the increase of deformity is to be prevented. 

Recurrence of Disease and Later Effects of Deformity. — The 
disease may recur after an interval of many years of apparent cure and 
such recurrences are sometimes accompanied by the formation of an 
abscess or by paralysis. 

If recovery from Pott's disease has been complete and if deformity 
has been prevented, the condition of the patient is to all intents nor- 
mal, but if the course of the disease has been prolonged and if the de- 
formity is great, his condition is abnormal ; he is unfitted for ordinary 
occupations, and comparative comfort is assured only by constant care. 
Such individuals are likely to suffer from neuralgic pain about the 
weakened spine on over-exertion or whenever the general condition is 
depressed from any cause. In such cases the use of some form of light 
corset adds to the comfort of the patient. 

Secondary Deformities. — While the patient is under treatment for 
Pott's disease one should be on the alert to prevent other deformities that 
may follow the general weakness and restriction of normal functions. 
One of these is the weak foot, sometimes called weak ankle or flat foot, 
and with it is often associated a moderate degree of knock knee. This 
may be prevented by the use of a Waukenphast shoe, of which the 
heel and sole should be raised one-fourth of an inch on the inner side. 

Recapitulation. — Fixation on the portable frame is the treatment of 
choice in infancy and early childhood, without regard to the situation 
of the disease. Ambulatory treatment is the treatment of selection in 
later childhood, adolescence and adult life. 

Horizontal fixation is by far the most effective treatment of the local 
disease and deformity ; it is therefore the treatment that is held in re- 
serve to meet emergencies, when symptoms are not relieved, when de- 
formity is advancing and when complications are troublesome. The 
disadvantages of the treatment are evident although likely to be exag- 
gerated. The young child fixed upon the frame may be carried about 
in the open air, but the older patient is moved about with more diffi- 
culty and is likely on this account to be deprived of the stimulation of 
outdoor life as well as of exercise. 

Ambulatory treatment must always supplement that by recumbency, 
and in the great majority of cases it is the treatment of necessity and 
routine. Its efficiency will depend, in great measure, upon the careful 
regulation of the strain which the erect posture and the activity of the 
patient throws upon the weakened spine. 

Of the relative merits of the supports that have been described it 
may be stated that the plaster jacket has the great advantage of cheap- 
ness ; its use places the treatment in the hands of the surgeon, and in 
the middle region of the spine, it is equal to, and may even be supe- 
rior to, the brace. The laced corset is not equal as a support to the 
solid jacket. 



FORCIBLE CORRECTION OF THE DEFORMITY. 101 

The back brace has a wider range of adaptability than the jacket. 
Its disadvantages are the original expense, the difficulty of accurate 
adjustment and the fact that it can be removed by the parents, who are 
inclined to neglect medical supervision, when the use of the apparatus 
has become familiar to them. 

The jury mast, although a very useful appliance under certain cir- 
cumstances, is inferior to the metallic head rest when accurate fixation 
or support is desired. 

The complications of Pott's disease, abscess and paralysis, should be 
considered and treated as symptoms only, symptoms that may or may 
not require direct treatment according to the indications that have 
been described. Finally one should always bear in mind that the 
final cure of the disease depends upon the increase of the vital force ; 
thus the importance of fostering and improving the general well-being 
of the patient cannot be too strongly urged. 

Forcible Correction of the Deformity of Pott's Disease. Ca- 
lot's Operation. — Forcible correction of the deformities of the spine 
was advocated by several of the ancient writers, notably by Hippo- 
crates and by Pare, but in modern times, with the better understand- 
ing of the pathology of Pott's disease, the direct deformity that a pa- 
tient presented when coming under treatment was supposed to be 
irremediable, since it represented actual destruction of bone. 

In 1896 this method of forcible correction of deformity which had 
been revived by Chipault several years before l was popularized by 
Calot of Berck sur Mer, 2 who claimed that it was particularly adapted 
to the treatment of the kyphosis of tuberculous disease. Originally 
he advocated the immediate correction of such deformity, although of 
long standing, even if chiseling through the anchylosed vertebrae and 
removal of the spinous processes were required, but operative treat- 
ment in this class of cases has now been practically abandoned. 

At the eleventh Congress of French Surgeons at Paris in 1897 
Calot outlined the operation as follows : In the recent cases. the de- 
formity was corrected by direct manual traction and by pressure on 
the kyphosis. The traction employed was estimated at 60 to 160 
pounds, the pressure at 30 to 80 pounds, but in the more resistant type 
it was well to reduce the deformity gradually, at several sittings. Of 
204 patients treated by this method, two died in two days, and three 
others of broncho-pneumonia several months after the operation. In 
one case partial paralysis appeared and in another an abscess was ob- 
served soon after the procedure. 

Since Calot' s original publication hundreds of operations have been 
performed with results not differing essentially from those that he re- 
ported. It has been demonstrated that the deformity of Pott's dis- 
ease, in more recent cases, can be partly or entirely corrected by force 
in one or more sittings Avith but little danger to the patient. 3 If the 

1 Travaux de neurologie Chir., 1895, 1896, 1897. 

2 Archiv prov. de Chir., February, 1897. T. 6, n. 2. 

3 Bradford and Cotton (Boston Med. and Surg. Journal, September 20, 1900) have 
recently analyzed the literature of Calot' s operation, viz : 



102 TUBERCULOUS DISEASE OF THE SPINE. 

disease is in the progressive stage, and if the operation is undertaken 
before adhesions and contractions have formed, the correction will be 
easy. If the disease is in the stage of repair, the correction will ne- 
cessitate forcible separation of contracted tissues and the breaking up, 
it may be, of an actual anchylosis. If an abscess be present, whose 
coverings are adherent to the surrounding parts, the forcible correc- 
tion may rupture its walls and alloAv the escape of the pus into the 
lung or pleural cavity. The more remote dangers are abscess or pa- 
ralysis due to a direct extension of the local process, or a general dis- 
semination of the tuberculous disease. 

If the spine is straightened it is evident that there must be an actual 
separation of the diseased parts ; the spine is, as it were, straightened 
on the hinge formed by the articulating surfaces of the transverse 
processes. (Fig. 4.) This is an attitude favorable to repair since 
compression and attrition can no longer aggravate the destructive 
process. If paralysis be present, induced in part by the compression 
of the softened tissues at the seat of disease, it may be relieved by the 
correction of the deformity. This point was illustrated in two cases 
at the Hospital for the Ruptured and Crippled by an immediate im- 
provement and rapid recovery from paraplegia after the operation. 

It must be borne in mind however that the operation is undertaken 
for the relief of deformity. It is certain that the spine can be straight- 
ened and that it can be retained for a time in the corrected position, 
but it is unlikely that the interval left between the upper and lower 
segments of the spine will be filled with new bone. This can only be 
decided by a study of final results many years after the operation. 

There is, as a rule, an immediate recurrence of a certain amount of de- 
formity because of the natural recoil toward the habitual posture, and 
because in many instances the straightening of the spine has been due to 
an obliteration of secondary curvature rather than to actual separation 
at the seat of disease, and finally even if the interval between the seg- 
ments were filled with calcified tissue, such bone does not grow as it con- 
tains no epiphyses, consequently this irregularity must become more and 
more marked with the growth of the child. In other words although 
the effect of the destructive disease on the spine can be modified it 
cannot be entirely remedied even by the most successful operation. 

The Selection of Cases for Forcible Correction. — The favorable 
cases are those in which the deformity is of comparatively short dura- 
Six hundred and thirty-nine cases were performed by thirty -four operators. Time 
elapsed varied from a few days up to three years or more. Of the separate detailed 
cases in 7 more than one year had elapsed ; in 35 more than six months. 

Deaths reported from all causes, 25 ; various diseases, 5 ; general tuberculosis, 4 ; 
trauma of the operation and chloroform, 5 ; intercurrent disease, 7. 

Immediate results : Respiratory embarrassment, 7 ; pain, 6 ; severe shock, 3. 

Abscess present before operation, 19 ; ruptured, 4 ; benefited or absorbed, 6 ; ap- 
peared after operation, 2. 

Paralysis present before operation, 23 ; relieved, 17 ; not relieved, 2 ; made worse, 
1. Paralysis appeared after correction in 4. 

Direct effect on deformity in 240 cases : Complete correction, 130 ; incomplete, 94. 

Result in 77 cases : No relapse, 20 ; some relapse, 50 ; total relapse, 7. 



CALOT'S OPERATION. 103 

tion, cases in which the adhesions and the accommodative changes in 
the soft parts are not sufficient to offer resistance to correction, and in 
which the internal organs have not been long displaced or compressed. 
Well-marked deformities of the middle and lower dorsal region are 
especially suitable for the operation. 

The most unfavorable cases are those of fixed deformity, in which 
repair is progressing or is completed, and in which the organs and 
tissues of the body have been changed in shape and function to accom- 
modate the new conditions. 

As a rule deformity of the lumbar and of the cervical regions is not 
sufficient to require forcible correction. 

The presence of an abscess in the posterior mediastinum or else- 
where if it be in the active or progressive stage should contraindicate 
the operation. On the other hand paralysis, which is most often a 
complication of diseases in the dorsal region, is not a contraindication. 

The Operation. — As ordinarily performed the patient having been 
prepared as for the application of a plaster jacket is anaesthetized and is 
then suspended face downward in the horizontal position by five assist- 
ants who make moderate steady traction upon each extremity and upon 
the head while the surgeon, standing by the side of the patient, gently 
presses downward directly upon the kyphosis, which in the favorable 
cases, is gradually obliterated, the straightening of the spine being ac- 
companied by the audible separation of adhesions. 

The force employed, as stated by Calot, is traction of 60 to 160 
pounds and pressure of from 30 to 80 pounds. As a rule the force is 
much less, and there is little danger from this source. Jones states 
that a traction force of nearly 600 pounds is required to dislocate the 
neck of a child two and one-half years of age ; that five men pulling 
in the manner above described, with a force that soon tires, rarely 
exceed a traction force of 175 pounds. 

If the correction is to be completed at the first attempt the spine is 
over-extended and while it is held in this attitude a plaster jacket is 
applied. If the disease is of the middle of the back, the head need 
not be included, but it is better to fix and draw the shoulders back- 
ward by including them in the plaster. Great care should be taken 
to prevent excoriation. Very long, thick, wide pads should be placed 
on either side of the spinous processes ; the iliac crests and other 
prominences should be protected and a so-called dinner pad should be 
inserted below the sternum, which may, when removed, allow addi- 
tional room for respiration. This is of great importance if the patient 
has not worn a plaster jacket before the operation. If the disease is of 
the upper dorsal region, the head must be included in the bandage. 
Calot suspends the anaesthetized patient as in the ordinary manner for 
applying a jacket ; other surgeons suspend the patient with the head 
downward during the application of this part of the bandage, but 
with a little care the head support may be applied with the patient in 
the horizontal position. 

The hair should be cut closely and protected from the plaster by a 



104 TUBERCULOUS DISEASE OF THE SPINE. 

well-fitting skull cap. The bandage is then continued over the head 
and neck as in the illustration. (Fig. 49.) A strip of malleable 
steel, bent to fit the occiput, may be incorporated in the bandage to 
give it sufficient strength. 

Many surgeons employ other supports than the plaster. One of the 
best forms of apparatus is the double Thomas brace used by Jones. 
The stretcher splint may be used also. 

In properly selected cases there is little shock after the operation, 
but if the change in the contour of the spine has been considerable, 
respiration may be somewhat embarrassed by the plaster jacket. In 
such cases it must be split through the front and separated. In all 
cases it is well to cut through the plaster at points where direct pres- 
sure is likely to be exerted, in order to guard against excoriations. 

As a rule the operation should be followed by prolonged rest on the 
back 3 to 6 months or longer to allow for adaptation to the new posi- 
tion and for consolidation, but as far as symptoms are concerned the 
patients may be up and about as usual in a few days if the spine can 
be held properly by the plaster jacket, as has been the case with many 
of the patients at the Hospital for Ruptured and Crippled. 

As has been stated there is a marked tendency toward recurrence of 
deformity. On this account some surgeons advocate wiring the spinous 
processes to one another as originally suggested by Hadra and practiced 
by Chipault. The operation is a simple one, but its efficacy is doubtful. 

In cases in which the deformity is of the resistant type it is well to 
divide the rectification into several sittings at intervals of a week or 
more. In many instances anaesthesia is not required after the first 
operation ; for traction and even the forcible pressure at the seat of 
disease do not appear to cause particular discomfort. 

Gradual Correction of Deformity. 

Corrective force may be applied also by methods that do not deserve 
the name operation. For example a certain amount of traction and pres- 
sure may be employed with advantage during the application of the plas- 
ter jacket in the ordinary manner if the cases are properly selected. 

But the most efficacious method of gradual or non-violent correction 
is that employed by Goldthwait l by horizontal traction and leverage. 
This method is described by him as follows : 

" The apparatus which has been used consists of a strong gas-pipe 
frame, six feet long by two feet wide. Suspended from this is a bar 
(a), in the center of which is a vertical rod (6), forked at the top and 
long enough to reach to the level of the frame. This crossbar is 
simply suspended from the frame so that its position can be changed 
as desired. Below this is another crossbar (c), which rests on the 
frame and can also be adjusted as to position. Upon this latter piece 
(c) and upon the fork of the rod (6) rest two malleable steel bars (d), 
about eighteen inches long. These rest in grooves one inch apart, and 

1 Trans. Am. Ortho. Ass'n, Vol. XL, p. 95. 



CALOTS OPERATION. 



105 



should be bent to partly conform with the lumbar curve of the spine, 
after which they are heavily padded with felt and the patient laid 
upon them. The upper end of the bars (d) should just rest upon the 
fork, not projecting over, and when the patient is in position the rod 
should be one inch above the apex of the deformity. The buttocks 
rest upon the crossbar (c), and the legs are supported by one or more 
heavy webbing straps which can be tightened or loosened at will. No 
support whatever is given the upper part of the body, except that 
the head is steadied by the surgeon with the hand until a satisfactory 
amount of correction has been accomplished, and then a strap similar 
to those used below gives the support so that the operator's hand is 
free. If traction is desirable, it can be applied by means of a wind- 
lass which is attached to each end of the frame. This makes it pos- 



Fig. 58. 




The plaster jacket applied in supine posture by means of the Metzger-Goldthwait apparatus. 



sible to obtain much more definite and steady traction than would be 
possible with assistants, but its use has not been found necessary in 
the majority of the cases, simple over-extension of the spine accom- 
plishing the same results. 

^Yhen the maximum over-extension that is desirable is obtained, the 
strap under the head is fastened and the patient allowed to lie in this 
position while the jacket is applied. In applying this the iliac crests 
should be generously padded with heavy felt and a similar pad should 
be placed over the upper part of the sternum so that the jacket can 
be carried high up to prevent the upper part of the body with the 
shoulders from drooping forward. In the cases with disease in the 
upper dorsal region the jacket should be moulded about the anterior 
part of the neck so that erect position of the head is necessary. The 
forked rod (b) is easily avoided by a few figure-of-eight turns of the 



106 TUBERCULOUS DISEASE OF THE SPINE. 

bandage, so that when the plaster has set the patient can easily be 
lifted off, and as the rod (6) should be placed one inch above the apex 
of the deformity this weak spot in the jacket is not objectionable. 

When the patient is taken off the frame the two rods (d) are slipped 
out from below leaving the padding in place. 

As a matter of experience it has been found necessary to practically 
always cut a small window over the point of greatest deformity as 
otherwise when the body settles down, as is inevitable, a slough will 
form even though a liberal amount of padding has been used. This 
procedure is repeated from time to time until the best possible attitude 
has been obtained. This method originally devised as a modification 
of the Calot method of forcible correction of deformity is now em- 
ployed in the routine application of the plaster jacket. For this pur- 
pose Goldthwait uses a portable frame as shown in the illustration. 

It may be stated of forcible correction of the spine (Calot' s opera- 

Fig. 59. 




Goldthwait's portable frame for applying the plaster jacket. (See Fig. 46.) 

tion), that it is in no sense curative ; that although it has been proved 
that the back can be straightened, in many instances with ease and in 
most cases with but little danger, yet the retention of the spine in the 
corrected position is difficult, and a certain immediate recoil toward 
deformity is the rule. Even if the interval between the two seg- 
ments be filled with new bone, the growth of the spine at this point 
being checked, an increase of the irregularity with advancing years 
may be expected. In fact, correction of deformity is in no sense a 
substitute for prevention. The ease with which correction may be 
made in early cases, emphasizes the importance of rest on the back, in 
the over-extended attitude, as a means of correcting deformity, in cases 
in which operative intervention seems to be contra-indicated. 

The final judgment can not be passed upon this procedure for many 
years ; it has rapidly lost favor during the past year, partly because of 
recurrence of deformity, and partly because experience has shown that 
the same degree of rectification may be attained by milder methods. 



CHAPTER II. 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 



Syphilis. 

This disease, in the inherited or in the later stages of the acquired 
form, may affect the bones of the spine and cause local deformity and 
symptoms that cannot be distinguished from those of Pott's disease. 

Diagnosis. — As compared with tuberculosis, it is a rare disease of 
the spine. Its manifestations are likely to be general in character, the 
deformity of the spine being but one of many evidences of disease. ~> 

If syphilis were limited to the spine 
Fig. 60. and simulated the symptoms and the 

deformity of Pott's disease, it would 
demand the same local treatment. 
Specific remedies should always be ad- 
ministered when one has reason to sus- 
pect its presence, as in the treatment 
of syphilitic disease of other parts. 

Malignant Disease of the Spine. 

Malignant disease of the spine is a 
rare affection, particularly so in child- 
hood. Sarcoma is more common than 
carcinoma, which, when it affects the 
spine, is almost always secondary to a 
primary tumor elsewhere, as of the 
breast. 

Diagnosis. — Malignant disease dif- 
fers from tuberculosis of the spine in 
that its symptoms are usually more 
severe ; the pain is usually persistent 
and it is not relieved by support or 
recumbency, as is that of Pott's disease. 
The constitutional symptoms are more 
marked and the steady progress of the 
disease toward a fatal termination is 
soon apparent. Locally, the angular deformity is usually slight and it 
may be absent. Not infrequently the tumor may be palpated through the 
abdominal wall. Paralysis is a frequent, and often an early, symptom. 
As has been stated, carcinoma is almost always secondary, but sar- 




Vertical anteroposterior section of 
lumbar spine showing deposit of gumma 
in the posterior part of the third and 
fourth vertebra? (after Fouenier). 



108 NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 

coma of the spine may be the primary focus of disease ; in such cases 
diagnosis in the early stage is often impossible. 

Malignant disease of the spine is a fatal affection and the treatment 
can be but palliative. 

Acute Osteomyelitis of the Spine. 

Infectious osteomyelitis of the spine is uncommon, but 41 cases are 
recorded in literature. 1 

Symptoms. — Its symptoms are similar to those of acute infectious 
processes elsewhere and are characterized by sudden onset, with pain, 
fever and constitutional depression. There is local pain and tender- 
ness about the spine. Abscess quickly forms ; and paralysis, from 
the rapid extension of the disease is a common complication. 2 The 
symptoms due to pyogenic infection and to deep-seated abscess, are 
often pysemic in character, and necrosis of the affected vertebral bodies 
may result in the formation of large sequestra. The death rate is 
about 50 per cent. 

Treatment. — The treatment consists in the immediate evacuation 
and drainage of the abscess, the removal of the necrosed bone if pos- 
sible, and in supporting the spine during the subsequent stage of weak- 
ness. 

A more localized and more chronic form of osteomyelitis may oc- 
cur, but it is practically impossible to distinguish its symptoms from 
those of tuberculous disease. 

Actinomycosis of the Spine. 

Actinomycosis of the spine is an extremely rare disease and need 
only be mentioned as a possibility. Its diagnosis may be made by 
the microscopic examination of the discharge from the sinuses that al- 
most always form early in the course of the disease. 

Injury of the Spine. 

Severe sprains or fractures may simulate disease very closely and in 
some instances, particularly injury of the cervical region, diagnosis is 
practically impossible until after treatment by support and fixation 
has been applied ; when, as a rule, if disease be absent, the symptoms, 
even though of long standing, quickly subside. 

Fracture of the spine in the middle region may result in angular 
deformity, and when proper support has been neglected, symptoms of 
pain and weakness, similar to those of Pott's disease, may persist in- 
definitely. 

Sudden forcible compression of one or more of the vertebral bodies 
without displacement and without severe immediate symptoms, other 
than the slight deformity, may be the result of injury, especially falls 

1 Halm, Beitrage zur klin. Chir., Bd. XXV., H. 1, 1899. 
2 Muller, Deutsche Zeits. fur Chir., Bd. 41. 



THE RHACHITIC SPINE. 



109 



from a height. These cases are not uncommon and are usually mis- 
taken for Pott's disease. 

Diagnosis. — The diagnosis should be made clear by the history. 

Treatment. — In all such cases, and whenever weakness of the 
spine persists, and when motion causes pain, a support should be ap- 
plied. Fracture of the spine should be treated as is fracture else- 
where, by reposition of the fragments, if possible or practicable, and 
by support, until the integrity of the parts has been reestablished. 



Traumatic Spondylitis. 

Kummell x has described a form of rarefying ostitis of the spine of 
non-tuberculous origin, apparently caused by injury. It is character- 
ized by symptoms of pain and weakness referred to the back, and by 
pronounced rounded ky- 
phosis of the dorsal region. Fig. 61. 
Motor disturbances of the 
lower extremities are fre- 
quent. The treatment is 
similar to that of Pott's 
disease. The nature of the 
affection, if it be a distinct 
variety of disease, is doubt- 
ful. 

The Rhachitic Spine. 

The rhachitic spine has 
been described in the con- 
sideration of the differential 
diagnosis of Pott's disease 
(p. 45). It most often de- 
velops during the first or 
second year of life, in child- 
ren who sit the greater part 
of the time. It is, in fact, 
simply an exaggeration of 
the contour which is nor- 
mal in the sitting posture ; 
the typical rhachitic ky- 
phosis is thus a rounded 
projection of the lower re- 
gion of the spine, which is 
more or less rigid according 
to its duration. If the deformity is extreme, there is often a compensa- 
tory backward inclination of the head which may be exaggerated by 
contraction of the posterior group of muscles, " cervical opisthotonos." 

1 Kummell, Deutsche med. Wochens., 1895, N. 11. 




Rhachitic kyphosis. 



110 NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 

Treatment. — Aside from the constitutional treatment of the rhachitic 
condition, and from the measures that should be employed to improve 
the nutrition of the muscles in general, the indications are to overcome 
the rigidity and the limitation of motion in the spine ; to support it, if 
necessary, during the stage of weakness ; and to remove, if possible, 
the predisposing causes. 

The correction of the deformity may be accomplished by massage, 
and by direct manipulation of the spine. The child is placed, face 
downward, on a table ; one hand is applied over the projection, and 
with the other the legs are raised to throw the spine into a position of 
over-extension. This stretching is performed slowly and carefully 
over and over again at morning and night, and the manipulation is 
followed by thorough massage of the muscles. If the deformity is 
marked and if the general rhachitic process is still active, the infant 
may be kept for several months in the recumbent posture, on the frame 
or similar support. 

In older subjects some form of light back brace may be sufficient 
in connection with the massage, and systematic correction of the de- 
formity. 

The Natural Cure. — It may be stated that the rhachitic spine is to a 
certain extent corrected when the erect posture is assumed, by the in- 
clination of the pelvis and accompanying lordosis. This natural cure 
is however often rather a distribution of deformity than a cure, for the 
upper part of the projection may remain as an exaggeration of the 
normal dorsal kyphosis balanced by an exaggerated lordosis, " the 
rhachitic attitude." And in other instances the persistence of the 
lumbar kyphosis may induce a compensatory flattening of the normal 
dorsal kyphosis. Thus rhachitis may cause the so-called flat back, as 
well. 

PAINFUL AFFECTIONS OF THE SPINE NOT ATTENDED BY 
ANGULAR DEFORMITY. 

Infectious Disease of the Coverings or Articulations of the 
Spine. " The Typhoid Spine." (Gibney.) 

During the course of, or during convalescence from, typhoid fever, 
and occasionally after apparent recovery from the disease, symptoms 
of pain, weakness and stiffness of the back may appear. These are 
caused apparently by secondary infection of the fibrous coverings and 
attachments of the spine, similar to the more common, but more severe, 
forms of periostitis of the tibia or other bones, from the same cause. 
There is usually pain on motion and pain on pressure over the affected 
vertebrae. 

Diagnosis. — The diagnosis is usually made clear by the history of 
the disease of which it is a complication. 

Treatment. — The treatment should be symptomatic. During the 
active stage, if pain is severe, the patient should be kept in the recum- 
bent position and opiates may be administered if necessary. Locally, 



SPONDYLITIS DEFORMANS. 



Ill 



Fig. 62. 



the application of the Paquelin cautery is of service. As soon as is 
practicable a back brace should be applied, which may be worn until 
the symptoms have subsided. Recovery may be predicted although a 
certain amount of restriction of motion may persist. 

Symptoms resembling these may follow other forms of contagious 
disease, notably scarlet fever, but as a rule they are much less persis- 
tent and severe. 

Gonorrhceal Rheumatism of the Spine. 

"Gonorrheal rheumatism" of the spine is rare. Its symptoms resem- 
ble those of the typhoid spine. Anchylosis is, however, more common 
as a result ; in fact infection of 
this character is supposed to be 
one of the causes of spondylitis 
deformans. 

Locally massage, and support 
to prevent deformity, are indi- 
cated. 

Arthritis of the Spine. 

The smaller joints of the 
occipito-axoid region are some- 
times affected by what appears 
to be a form of acute infectious 
arthritis similar in symptoms to 
acute rheumatism of this region 
but strictly localized. It may 
follow tonsilitis, diphtheria or 
other contagious disease. It 
may be distinguished from tu- 
berculous disease by its acute 
onset and from acute torticollis 
by the fact that all motions are 
restricted. 

Treatment. — The treatment 
consists in support during the 
acute stage followed by massage 
and manipulation to overcome 

the Subsequent StllfneSS. Spondylitis deformans. (Goldthwait. 




Spondylitis Deformans. 

Synonyms. — Osteo-arthritis of the Spine — Rheumatism of the 
Spine — Spondylose Rhizomelique — Stiffness of the Vertebral Column. 

Spondylitis deformans is an inflammatory affection of the spine ter- 
minating in ankylosis and deformity. 

Pathology. — The disease is apparently a chronic inflammation 
which affects primarily the ligaments and the periosteal coverings of 



112 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 



Fig. 63. 



the spine, a form of ossifying periostitis which binds the vertebrae firmly 
to one another. (Fig. 62.) It may begin on the lateral or on the anterior 
aspect of the spine ; it may be limited to a particular region, but in 
most instances it involves the entire spine and often the articulations 
of the ribs as well. The intervertebral discs atrophy, but in some in- 
stances the margins of the cartilages 
proliferate and become ossified in a 
manner characteristic of osteoarthri- 
tis of the joints. 

Under the general term of spondy- 
litis deformans are included, in all 
probability, several varieties of dis- 
ease ; for example : 

1 . The anchylosis of the spine may 
be simply a part of a general rheu- 
matoid arthritis — Rheumatoid Ar- 
thritis of the Spine. 

2. The spine may be involved to- 
gether with one or more of the ad- 
jacent joints which show the char- 
acteristic symptoms of the hyper- 
trophic form of rheumatoid arthritis. 
Osteo-arthritis of the Spine. This 
form has been designated by Marie 
as Spondylose Rhizomelique, spon- 
dylos-spine, rhizo-root, melos-ex- 
tremity, signifying a disease of the 
spine together with the adjoining 
" root " joints. 1 

3. The disease may be limited to 
the spine and in such cases it ap- 
pears to be entirely distinct from 
rheumatoid arthritis. It may follow 
acute rheumatism, it may be induced 
apparently by gonorrhoea, or by 
other forms of infection. It may 
begin acutely like inflammatory 

rheumatism or it may be chronic in character and progress slowly. 2 
Symptoms. — In the ordinary cases there is usually an acute onset 
from which the patient dates the beginning of his trouble, followed by 
a gradually increasing stiffness of the spine and accompanying de- 
formity. The patient complains of stiffness, weakness, pain in the 
loins and of pain radiating forward along the ribs. Sometimes symp- 
toms of weakness in the limbs, headache, nervousness and the like are 
present, symptoms that may be explained in part by the inflammatory 




Spondylitis deformans in a child. 



i Marie, Eevue de Med., Vol. 18, 1898. 
2 Bechterew, Neurol. Centb., Vol. II., p. 426. 
20, 1897. 



Senator, Berlin, klin. Wochen., Nov. 



SPOND Y LITIS DEFOR MANS. 



113 



process and by implication of the nerve roots and in part by an accom- 
panying neurasthenia. The direct symptoms are increased by jars 
which are exaggerated by the inelasticity of the spine. The disease is 
usually progressive and terminates finally in complete rigidity of the 
spine which is bent into a long kyphosis most marked in the upper 
dorsal region, the lumbar lordosis being obliterated in many instances. 
(Fig. 62.) 

When the disease is limited to the spine and larger joints, the occi- 
pito-axoid articulations are not usually involved. 

The types of the disease may be 
illustrated by a brief description of Fig. 64. 

four cases recently under observa- 
tion. 

Case 1. Chronic Rheumatoid 
Arthritis of the Spine. — In this 
case, in a boy ten years of age, there 
was characteristic general rheuma- 
toid arthritis that involved nearly 
every joint of the body. The entire 
spine, even including the occipito- 
axoid joints, was rigid and the head 
was fixed in an attitude of extreme 
torticollis. 

Case 2. Osteo-arthritis of the 
Spine. — " Spondylose Rhizome- 
lique." A man forty-six years of 
age, after repeated attacks of so- 
called rheumatism involving the 
larger joints, became gradually dis- 
abled because of pain and stiffness 
of the back and because of his 
inability to stand erect. In this 
case there was complete anchylosis 
of the spine except of the small 
joints of the cervical region, and 
in addition the right thigh was 
flexed upon the body at such an 
angle that the patient could walk 
only with an exaggerated stoop. 
The joints of the feet were slightly 
involved also. No cause other 
than exposure to cold and dampness 

could be assigned. The 'symptoms were of two years' duration, periods 
of comfort alternating with disabling attacks of " rheumatism. " 

Case 3. Spondylitis Deformans. — The spine of this patient, a man 

forty-six years of age, was absolutely anchylosed in the characteristic 

position. The occipito-axoid joints were not involved. Fourteen 

years before, he had suffered from a severe and prolonged attack of in- 

8 




Extreme posterior curvature of the spiue 
in adolescence, showing retraction of the ab- 
domen. 



114 NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 

flammatory rheumatism, affecting nearly every joint, but not the spine, 
and during a succeeding period of nine years he had been disabled 
several times from the same cause. Each illness was coincident with 
gonorrhoea. Five years before examination the rheumatism had in- 
volved the spine and since then he had suffered from persistent " lum- 
bago." Gradually the stiffness of the spine had increased, but during 
this time he had been free from gonorrhoea and from rheumatism as 
well. The joints were normal in appearance and function. This pa- 
tient suffers principally from nervousness and irritability ; he is easily 
startled, he feels as if his forehead were clasped by a tight band. 
His direct symptoms are pain in the loins and pain radiating under 
the shoulder blades, increased by walking or by jars. His equilibrium 
is disturbed by the forward projection of the head and by the obliter- 
ation of the normal lordosis, so that he feels himself constantly inclined 
to fall forward, whether he is sitting or standing. 

Case 4. — In another case very similar to this, in a man thirty years 
of age, the spine had become rigid in a few months. The patient 
ascribed the disease to sleeping out of doors. There was in this case 
coincident disease of the lungs. 

Treatment. — The local treatment is symptomatic. The application 
of cautery adds to the patient's comfort, and self suspension at inter- 
vals may relieve the dragging sensation in the muscles. Rubber heels 
are of service in lessening the jar. A brace may be applied if the pain is 
aggravated by motion ; it may also serve together with the avoidance 
of predisposing attitudes to prevent extreme deformity of the spine. 

Kyphosis of Adolescents. — A form of extreme kyphosis accompanied 
by stiffness and discomfort is sometimes seen. It appears to be a static 
deformity induced by over-work, in rapidly growing adolescents. It 
can hardly be classified with spondylitis deformans, although there may 
be some difficulty in distinguishing between the two. (Fig. 61.) 

Osteitis Deformans. 

Synonym. — Paget' s Disease. 

Osteitis deformans is a general disease characterized by hypertrophy 
and softening of the bones. The deformity of the spine is similar to 
that of rheumatoid arthritis, but the rigidity of the spine is not as ex- 
treme. The disease is described elsewhere. 



PAINFUL AFFECTIONS OF THE SPINE NOT ATTENDED 
BY RIGIDITY. 

The Neurotic Spine, 

The " neurotic' ' spine is much more common in adolescence and in 
adult life than in childhood, and it is much more often observed in 
females than in males. The subjects are usually of a nervous or neu- 
rasthenic type, although in certain instances the symptoms appear to 
be the direct result of injury. 






THE HYSTERICAL SPINE. 



115 



Fig. 65. 



Symptoms. — The patient usually complains of a dull pain in the 
back of the neck, or in the lumbar or sacral region, of a constant 
tired feeling, and, not infrequently, of sharp neuralgic pain localized 
about a certain point in the spine, often the vertebra prominens. The 
contour of the spine may be normal, but most often there is a well- 
marked tendency toward a forward droop, the curve of weakness. (Fig. 
65.) One of the characteristics of the neurotic spine is the extreme local 
tenderness, or hyperesthesia, of the skin at certain points along the 
spinous processes. Thus if one passes the finger gently along the spine, 
the patient will often shrink or cry out, because of the pain. As a 
rule there is no limitation of 
motion or muscular spasm. 
The pain is local, not re- 
ferred to the terminations of 
the nerves ; in fact the symp- 
toms are, in great part, 
subjective and irregular in 
character as contrasted with 
those of Pott's disease which 
are objective and well de- 
fined. 

Treatment. — The treat- 
ment of the neurotic spine 
must be general in character 
as indicated by the condition 
of the patient. Locally, a 
light back brace or a long 
steel corset reinforced with 
steel bands, combined with 
the application of the cau- 
tery, is useful as a prelimi- 
nary treatment. Later, mas- 
sage and exercises may be 
employed. Complete recov- 
ery is usually long delayed. 

The Hysterical Spine. 

The hysterical spine is 
considered usually as sy- 
nonymous with the neurotic 
spine, but as there are many 

individuals who suffer from sensitive spines who are not hysterical, it 
would seem proper to limit the latter term to the hysterical class. 

Symptoms. — The symptoms do not differ particularly from those of 
the neurotic spine except that in certain instances actual deformity 
may be present ; usually exaggerated lateral distortion, most marked 
in the lumbar region. Such cases are often supposed to be the effe ct 




The neurotic spine. Characteristic attitude. 



116 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 



of injury, particularly of blows upon the back, but except as a pos- 
sible cause of the appearance of a particular manifestation of the men- 
tal condition, injury could not explain the symptoms or the deformity. 
Treatment. — The local treatment is similar to that of the neurotic 



spine. 



Pain in the Lower Part of the Back. 



Pain in the lumbar region of the character of tire, weakness, or even 
of more extreme discomfort, is sometimes an accompaniment of dis- 
ease or displacement of the pelvic or abdominal organs. Pain in this 
region is also a common symptom among overworked women. It is 
particularly troublesome when for any reason the lumbar lordosis is 
exaggerated temporarily, as during pregnancy, or permanently as a 
compensatory deformity for dorsal Pott's disease, or because of flexion 
of the thigh after hip disease. 

As a result of strain or injury symptoms of pain and weakness in 
the lumbar region increased by sudden motions or over-exertion, may 
be persistent and disabling. Such cases are often classed as chronic 
lumbago and are probably the result of strain of the ligaments or deep 
muscles of the spine aggravated it may be, in certain instances, by 
rheumatism or other general affection of like character. 

The treatment must be primarily directed to the condition of which 
the pain is a symptom. 

When motion causes pain and when the symptoms are persistent, 
as in the lumbago type of cases, support in the form of a back brace, is 
indicated, the Knight brace or plaster corset being convenient forms. 

During the more acute stage the ap- 
plication of the cautery and the sup- 
port of intersecting strips of adhesive 
plaster, covering a wide area, will often 
relieve the pain. Later, massage, elec- 
tricity and the like may be of service. 

Spondylolisthesis. 

Spondylolisthesis is a deformity in 
which the body of one of the lower lum- 
bar vertebrae, most often the fifth, is dis- 
placed forward and downward. (Fig. 
66.) The displacement is peculiar in 
that the spinous process may remain in 
its normal position, while the laminae 
become elongated or separated from the 
displaced body. The condition was 
first described by Killian in 1854 and it was very thoroughly inves- 
tigated by Neugebauer ] in 1890. 

The supposed causes are congenital malformation, injury and pos- 

>Lovett, Trans. Am. Ortho. Ass'n, Vol. X., p. 22. 



Fig. 66. 




Small pelvis of Prague (median section). 
Instance of slight forward displacement of 
fifth lumbar vertebra. (Neugebauer.) 



SACRO-ILIAC DISEASE. 117 

sibly disease of the lumbosacral articulation. Lane states that slighter 
degrees of the deformity are often observed among laborers. The 
effect of the displacement is to exaggerate the lumbar lordosis and to 
increase the prominence of the sacrum and of the iliac crests. The 
deformity is most often seen in women in whom it causes, in many 
instances, no particular symptoms, in fact its chief interest lies in its 
effect upon child-birth. As a rule, however, as has been stated in the 
preceding section, an increase of the lumbar lordosis is usually at- 
tended by a certain degree of discomfort and pain. 

Lovett ! has described a case in which the deformity was the result 
of direct injury. The patient, a young man, was successfully treated 
by a plaster jacket. Such cases, and those in which displacement is 
the result of disease, may require orthopaedic treatment by braces or 
other support, for the relief of pain and for the prevention of further 
deformity. 

Deformity Secondary to Sciatica. 

Synonym. — Sciatic Scoliosis. 

Severe sciatica often induces a change in the attitude and contour 
of the spine that may become a permanent deformity if its cause per- 
sists. As a rule the patient habitually inclines the body away from 
the painful part, in order to relieve the leg from weight, and bends 
the body slightly forward and abducts the limb to relax the tension on 
the sensitive nerve or plexus of nerves. Thus the pelvis on the affected 
side projects, there is a lateral lumbar convexity toward the opposite 
side, and often the normal lumbar lordosis is lessened or lost so that the 
final result may be a persistent lateral curvature, together with a change 
in the antero-posterior contour of the spine. (Fig. 66.) If the sci- 
atica is a symptom of a more widespread neuritis, muscular weakness 
and muscular spasm may cause variations in the typical attitude, but 
this is unusual. 

It must be borne in mind that disease of the lumbar spine, or of the 
pelvic bones or joints, or disease of the adjacent organs or pa'rts may 
set up sciatica ; thus the cause of the pain should be carefully sought for. 

Aside from the direct treatment of sciatica, support for the spine, 
preferably a light corset, may be indicated, if motion aggravates the 
pain or if the deformity persists. 

Neuritis in other regions of the spine may cause symptoms of re- 
flected pain and local sensitiveness. These symptoms are increased 
by motion, and a certain amount of local deformity, similar in charac- 
ter to that due to sciatica, may be present. 

The treatment is similar to that indicated in the former affection. 

Sacro-Iliac Disease. 

Tuberculous disease of the sacro-iliac articulation is a rare affection, 
and extremely so in childhood. 

Symptoms. — The symptoms are pain, weakness, limp and change 
in attitude. The pain is referred to the side of the pelvis or radi- 

1 Trans. Am. Ortho. Ass'n, Vol. X. 



118 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 



Fig. 



ates over the buttock or thigh. It is increased by jars, by turning 
the body suddenly, sometimes by coughing or laughing; and a pe- 
culiar feeling of insecurity and weakness is sometimes complained 
of. As a rule the body is inclined toward the sound limb, thus the 

pelvis is lowered on the affected side 
and the leg seems longer than its fellow. 
In the early stage of the disease there is 
no deformity of the limb, but if a pelvic 
abscess forms, the thigh may become 
flexed. Locally, there may be sensitive- 
ness to pressure on the articulation, and 
swelling in the neighborhood of the dis- 
ease, although this is usually a late symp- 
tom. Pain is induced by lateral pres- 
sure on the pelvis or by any manipula- 
tion that disturbs the articulation. 

Abscess finally forms in the majority 
of cases. It may be extra- or intra- 
pelvic. The intra-pelvic abscess may 
present above the crest of the ilium, or 
the pus may pass through the sciatic 
notch, or appear in the ischio-rectal 
fossa, or break into the rectum. 

Diagnosis. — Sacro-iliac disease may 
be mistaken for sciatica, or for disease 
of the hip on spine. The freedom of 
motion and the absence of muscular 
spasm when the pelvis is fixed, if the 
examination is carefully conducted, 
should exclude both the one and the 
other, although the pain on lateral 
pressure which is described as the most 
characteristic symptom, may be simu- 
lated closely by primary acetabular dis- 
ease. The attitude is similar to that of 
sciatica, hut the symptoms of local sen- 
sitiveness to jars and to manipulation 
are much more marked. 

Prognosis. — According to the statis- 
tics the prognosis is very unfavorable, 
probably because the majority of the 
reported cases were in adults and were 
complicated by infected and burrowing 
abscesses, which constitute the chief danger of this form of tuberculous 
disease. 

Treatment. — The local treatment consists in protecting the diseased 
parts from injury, and in the radical removal of the disease if it has 
reached the stage of abscess formation. 




Deformity caused by persistent 
sciatica of the right side. This atti- 
tude is similar to that symptomatic of 
sacro-iliac disease. 



SACBO-ILIAC DISEASE. 119 

In the ambulatory treatment, a plaster spica bandage, or a double 
Thomas hip brace combined with the use of crutches may be indicated, 
but in most instances a broad, strong pelvic girdle which may be 
drawn tightly about the pelvis, will be most efficient. If motion of 
the spine causes discomfort, this girdle may be reinforced by some 
from of spinal brace. If the disease is progressive rest in bed will be 
necessary. 

When abscess is present radical treatment is, as a rule, indicated. 
The articulation should be freely exposed and the diseased boue should 
be entirely removed, if possible. Intra-pelvic abscess should be 
drained through a direct communication, in order to check, if possible, 
the tendency toward burrowing. 

Injury of the Sacroiliac Articulation. — In some instances 
the symptoms of sacro-iliac disease are apparently due directly to falls 
on the buttock or pelvis. In such cases the symptoms are readily re- 
lieved by support, and the presence of actual disease seems to be doubt- 
ful. 



CHAPTER III. 



LATERAL CURVATURE OF THE SPINE. 



Fig. 68. 



Synonyms. — Rotary Lateral Curvature — Scoliosis. 
Lateral curvature of the spine is an habitual or fixed deformity in 
which the spine is deviated in whole or part to one or the other side of 
the median line. 

By limiting the term to habitual deformity one excludes simple 
postural inclination of the spine. For example, if one leg were con- 
siderably shorter than the other the pelvis would be tilted downward 

on the short side and there would be 
a compensatory curvature of the spine 
in the erect attitude, which would dis- 
appear in the sitting posture. This 
accommodative curvature, and those 
of similar origin, would not be desig- 
nated as lateral curvature of the spine. 
In persistent lateral curvature the 
anterior part of the column, made up 
of the bodies of the vertebrae that 
support the weight, is more distorted 
than are the spinous processes, be- 
cause lateral distortion is always ac- 
companied by a certain degree of 
twisting or rotation of the vertebral 
bodies. This rotation is in the direc- 
tion of the convexity of the curve, 
and as the bodies rotate the spinous 
processes are carried in the reverse 
direction. Thus it is that well- 
marked rotation may be present, al- 
though there may be comparatively 
little lateral deviation of the line of 
the spinous processes. 

In the physiological movements of 
the spine, simple, direct lateral mo- 
tion, that is, motion allowed by the 
small joints of the spine and by the 
lateral compression of the interverte- 
bral discs, is very limited ; the larger movements must be accom- 
panied by rotation of the vertebral bodies by which this continuous 
or solid part of the column is, as it were, forced from the shortened to- 




Physiological rotation accompanying 
flexion and lateral inclination of the trunk 
in the normal subject. 



SYNONYMS. 



121 



ward the lengthened side. (Fig. 68.) When for example, one flexes 
the head to bring the ear as near the shoulder as is possible there is 
necessarily an accompanying rotation of the chin in the opposite direc- 
tion caused by the twisting of the bodies of the cervical vertebrae 
toward the convexity of the curve. Thus torticollis, in which the neck 
is held in this attitude, causes often a fixed rotary lateral curvature of 
the cervical vertebra?. 

In the simple accommodative lateral inclination of the body to one 
side or the other, the change in contour of the spine would be more 
noticeable if it could be observed from the front rather than from the 
back, and as lateral curvature is simply a persistent deviation of the 
spine, one of the so-called static deformities which are directly induced 
or exaggerated by superin- 
cumbent weight, it is probable Fig. 69. 
that rotation of the vertebral 
bodies precedes, in most in- 
stances, the lateral distortion 
that first attracts attention. 

It is probable also that 
slight rotation may not cause 
at once an appreciable degree 
of external distortion, and 
although marked lateral cur- 
vature is necessarily combined 
with rotation, yet it is possible 
that a slight degree of direct 
lateral deviation may exist un- 
accompanied by appreciable 
rotation. Rotation is usually 
understood to imply fixed de- 
formity, while lateral devia- 
tion may mean simply an 
habitual posture ; but it is far 
simpler to consider the two 
as parts of one distortion. 
The true and important dis- 
tinction is between habitual 
deformity, implying the habit- 
ual assumption of an improper 
attitude in which the accom- 
modative changes in structure 
have not advanced sufficiently 
to prevent voluntary or pas- 
sive correction, and fixed deformity in which the chauges in the bones 
and other tissues have made cure difficult or impossible. The evidence 
of fixed deformity is rotation that persists after the lateral deviation has 
been overcome. It persists because the early and important changes 
must take place in the bodies of the vertebrae that support the weight, 




Congenital total scoliosis. Compare with Fig. 70. 



122 



LATERAL CURVATURE OF THE SPINE. 



but there is no reason to believe that habitual rotation as an accom- 
paniment of habitual lateral curvature may not be corrected if it be 
treated at the proper time. 

The necessity for dividing the weight about the center of gravity 
in order to balance the body in the upright position accounts for the 
distribution and effects of lateral curvature. As the normal contour 
of the spine is the necessary result of static conditions, a change from 
this normal relation of one part necessitates a corresponding change 
elsewhere. If there be a primary lumbar curvature and rotation to 
the left in the lower region, a corresponding lateral deviation and rota- 
tion to the right in the region above usually develops, thus restoring 
the balance of the body. This explains the ordinary S-shaped or 
double curve of scoliosis, one of which is primary and the other sec- 

Fig. 70. 




Congenital total scoliosis. The rotation is much greater than the lateral 
deviation. Compare with Fig. 69. 

ondary. These curves may divide the spine equally or there may be 
a long and a short one, and occasionally three distinct curves may be 
present. If the primary curve is slight, the secondary curvature will 
be slight also, and the primary curve persists doubtless for a time be- 
fore the secondary distortion appears. In some instances the spine 
may be bent laterally into one long curve, "total scoliosis." (Fig. 
68.) This is probably, in many instances at least, the initial stage of 
the ordinary type of scoliosis, the long curve being afterwards divided, 
although it may persist. In childhood, total scoliosis is often com- 
bined with general posterior curvature and it is peculiar in that the 
torsion of the vertebrse may be toward the concave instead of the con- 
vex side, as is usual, the torsion representing probably the early stages 
of the secondary or compensatory curve. 



ROTATION AND LATERAL DEVIATION 



123 



It has been stated that deformity of one part of the spine is usu- 
ally balanced by deformity of another. This enables the trunk to 
hold the erect posture and it restores its general symmetry. If, how- 
ever, a long lateral or a long posterior curvature persists, the weight 
can be balanced only by swaying the entire body on the pelvis, in the 



Fig. 71. 




Primary lumbar curvature to the left. A " flat back " marked rotation with 
but slight lateral curvature. 



direction opposed to the distortion. This restores the balance, but 
not the symmetry. (Fig. 63.) 

Rotation and Lateral Deviation. — Fixed rotation of the spine 
carries with it of course all the parts that are attached to it. When 
the patient stands in the erect attitude the simple lateral distortion is 
most noticeable, but when the body is bent forward the twist of the 
trunk becomes the prominent deformity. (Fig. 69.) If the thoracic 
region is involved, the ribs, on the side toward which the spine is 



124 



LATERAL CURVATURE OE THE SPINE. 



rotated, project backward and on the other side of the spine there is 
an abnormal flatness or depression. The projection of the ribs due to 
the twisting of the thorax is far more noticeable than is the simple 
twisting of the free portions of the spine in the neck or loins ; and 
in these regions the projecting transverse processes covered by the thick 
layers of muscles yet unaccompanied by marked lateral deviation, 
may cause mistakes in diagnosis. In the cervical region, as an accom- 
paniment of acute torticollis, the projection may be mistaken for ab- 
scess; and in the lumbar re- 
Fm. 72. gion it has been mistaken for a 

new growth attached to the 
spine. 

Although persistent lateral 
curvature of the spine is al- 
ways accompanied by rota- 
tion, the degree of rotation 
does not always correspond to 
that of the more evident lat- 
eral deviation. In the instan- 
ces cited, extreme rotation in 
the lumbar region may exist 
with but slight lateral distor- 
tion ; while in other cases the 
body appears to be greatly 
displaced to one side, although 
there may be comparatively 
little fixed rotation. Again, 
as has been stated, the lateral 
deviation of the trunk is usu- 
ally more noticeable than the 
rotation, which in the slightest 
grades of deformity is only 
made apparent when the pa- 
tient is bent forward so that 
the back may be inspected in 
the horizontal position. It 
may be noted also that the de- 
gree of habitual lateral distor- 
tion of the body does not correspond to the degree of fixed distortion. 
One individual, by voluntary effort, may practically conceal advanced 
deformity, while another who makes no effort to correct the improper 
posture, appears to be greatly distorted although the fixed changes 
may be very slight. 

The effects of the deformity, both general and local, depend upon its 
situation and its degree. In one instance it may be so slight as to pass 
unnoticed, and in another the distortion may equal that of Pott's dis- 
ease. (Fig. 80.) If compensation be perfect, that is, if the deformity 
is equally distributed on either side of the median line, the general sym- 




Scoliosis with marked posterior deformity 



THE "HIGH" SHOULDER AND THE "HIGH" HIP. 125 

metry of the body may be but slightly disturbed. Or if the compen- 
sation for the primary deformity of the lumbar region is distributed 
throughout the remainder of the spine, noticeable distortion may be 
insignificant, but when there is a long curve involving the thoracic 
region, the lateral and posterior displacement cannot be concealed. 
(Fig. 73.) 

Changes in the Anteroposterior Contour. — Lateral distor- 
tion involves also secondary changes in the antero-posterior outline of 
the spine. When the distortion is marked the stature is shortened, 
sometimes very noticeably. This shortening is, of course, greater when 
the antero-posterior curves are increased in addition to the lateral de- 
viation. And, in general, one may recognize two types of lateral cur- 
vature, one in which the back is flatter than normal, in which the 
antero-posterior curves are diminished, and another in which they 
are increased. 

It has been stated in the account of Pott's disease that deformity in 
one segment of the spine always caused a change in the contour of the 
spine as a whole, that an obliteration or a lessening of the concavity 
of the lumbar region was accompanied by a corresponding flattening 
of the normal dorsal kyphosis. On the other hand, an increase in the 
backward projection of the dorsal region caused an increase in the 
concavity of the parts below. It is probable that the same explana- 
tion may account for the secondary changes in the antero-posterior 
contour of the spine in lateral curvature. In the one instance the 
primary deformity is of the lower region, and with its accompanying 
backward twist of the vertebral bodies it lessens the lumbar lordosis 
and tends to flatten the back. (Fig- 71.) If, on the other hand, the 
deformity begins in the thoracic region, the primary effect is to increase 
the backward projection, and this in turn tends to exaggerate the lum- 
bar lordosis. (Fig. 72.) Thus the shortening of the trunk caused by 
the lateral deviation may be to a certain extent compensated in the 
first instance, while in the other both the primary and secondary dis- 
tortions tend to reduce the height. 

The " High " Shoulder and the " High " Hip. — When the 
convexity of the primary curve is, for example, to the left in the lum- 
bar region, the trunk is displaced somewhat to the left, consequently 
the right " hip " becomes abnormally prominent ; and in compensation 
for the displacement below, there is a corresponding twist in the op- 
posite direction above. The spine bending, and at the same time ro- 
tating toward the right, carrying with it the ribs, elevates the shoulder 
and makes the scapula prominent. Thus it is that in the ordinary S- 
shaped curve the high shoulder and the projecting hip appear usually 
upon the same side of the body. But in less regular varieties of dis- 
tortion, when, for example, there is marked general lateral deviation, 
the high shoulder may be on the opposite side. (Fig. 79.) The final 
effect, as far as the lateral deviation is concerned, is much the same 
whether the curvature is primarily of the dorsal or of the lumbar re- 
gion, and there is much uncertainty as to the relative frequency of the 



126 



LATERAL CURVATURE ' b 0F THE SPINE. 



primary distortion because few cases are seen in the early stage or be- 
fore compensatory changes have appeared. 

Pathology. — Lateral curvature of the spine is a deformity, not'a dis- 
ease, nor is it in the ordinary cases a result of disease. For this reason 
the description of the pathology which is merely a more detailed ac- 
count of the deformity and of its secondary effects upon the trunk and 
its contents may, for convenience, precede the discussion of the etiology. 

In such a description one must consider the spine as a whole, a 
column bent and twisted, in which each component segment bears its 

Fig. 73. 




Scoliosis with extreme lateral deviation. 

share of the general distortion. The vertebra at the apex of each curve 
shows the greatest change. If the rotation and lateral deviation is to 
the right the vertebral body is somewhat wedge-shaped, the apex of 
the wedge being directed backward and to the left. Its lateral diam- 
eter is increased and the superior and inferior margins at the narrow 
side overhang the center of the body, increasing the lateral concavity. 
(Fig. 77.) Similar accommodative changes, although less marked, are 
to be found in the articular processes and in the laminae ; in fact all the 
parts on the concave side are broadened, shortened and lessened in 



PATHOLOGY. 



127 



vertical diameter as compared with those on the convex side of the 
spine. These changes affect the shape of the neural canal, which be- 
comes somewhat ovoid in outline, the base being directed toward the 





convexity of the curve. (Fig. 78.) In the vertebra? included in the 
compensatory curvature, the deformities are reversed, and the inter- 
mediate segments show the transitional changes between the two ex- 



128 



LATERAL CURVATURE OF THE SPINE. 



tremes. The intervertebral discs become wedge-shaped also, and atro- 
phied on the side subjected to greatest pressure, the changes in these 
softer tissues preceding, undoubtedly, those in the bones. The articu- 
lations of the vertebrae become changed in shape and position in the 
general adaptation to the deformity and the ligaments are shortened or 
lengthened according to their relation to the distortion. 

On section, the internal structure of the vertebrae shows the same 
adaptive changes that are evident on the exterior. In the narrowed 
parts of the bones that bear the weight, the tissue is thick and com- 
pact, and on the opposite side it is atrophied from disuse. 

Fig. 77. 




Scoliotic vertebrae. ( Hoffa. ) 



The mobility of the spine is lessened by these changes in its shape 
and structure ; primarily by the distortion, and by the shortening of 
the tissues on the concave side, finally by the interference of the newly 
formed, or transformed bone which is thrown out about the margins of 
the vertebrae and the articular processes, and by the distortions of the 
vertebral bodies. Thus in fixed deformity there may be, at the points 
of greatest distortion, practical anchylosis. The muscles of the back, 
both intrinsic and extrinsic, undergo adaptative changes, and, as a rule, 
they are, in general, relatively weak, and especially so if the motions 
of the spine are much interfered with. 

The distortion of the vertebral column causes, of course, a distortion 



PATHOLOGY. 



129 



of the trunk of which it is the support, and this distortion is of the 
greatest importance in its effect upon the thorax. The deformity of 
the thorax is somewhat difficult to describe because the distortion of 
the dorsal vertebrae does not affect the thorax equally, thus it is not 
twisted as a whole, nor flexed as a whole. The nature of the distor- 
tion may be better understood by considering the sternum as a fixed 
point ; this, as a matter of fact, it is, as compared with the spine. At 
the apex of the convexity of the curve the ribs are drawn sharply 
backward with the transverse processes to which they are attached ; their 
angles project by the side of, and beyond, sometimes covering and conceal- 
ing the spinous processes, and the lateral convexity of the chest is di- 
minished or lost. On the opposite side the back is broadened and flat- 
tened. The effect of the rota- 
tion is to diminish the capacity Fig. 78. 
of the chest, on the convex side 
and to increase that of the con- 
cave side. (Fig. 79.) On the 
convex side the ribs are ele- 
vated, and their inclination is 
increased. On the concave side 
the intercostal spaces are nar- 
rowed and the inclination is les- 
sened. (Fig. 75.) The antero- 
posterior diameter of the chest 
is increased or diminished ac- 
cording to the change in the 
antero-posterior contour of the 
spine. If the dorsal kyphosis 
is exaggerated, the effect is to 
deepen the chest (Fig. 72); if it 
is diminished, the diameter of 
the thorax is correspondingly 
lessened. 

The cervical section of the 
spine is not often involved, to 

a marked degree, at least in the lateral deformity. But in extreme cases, 
in which the neck and head are habitually distorted, the skull may show 
secondary changes similar to those induced by persistent torticollis. 

At the other extremity of the spine, the pelvis is not, as a rule, 
noticeably deformed. In some instances the oblique diameter, opposed 
to the convexity of the lumbar deformity, may be increased, and if the 
lateral deviation of the lumbar spine is extreme, the pelvis may be so 
tilted that the limb on the elevated side becomes practically shorter 
than its fellow. 

In the changes that have been described, the contents of the trunk 

participate to a greater or less degree. The lung on the convex side 

is more or less compressed by the distorted ribs and by the displaced 

vertebral bodies. The heart may be displaced laterally or upward, ac- 

9 




Change in shape of the spinal canal, broader on the 
convex side. (Hoffa.) 



130 LATERAL CURVATURE OF THE SPINE. 

cording to the position of the deformity, and the blood vessels are 
changed in direction, and, it may be, altered in calibre. In those cases 
in which the thorax is markedly distorted, the effect is similar to that 
of the deformity of Pott's disease ; respiration is shallow and rapid, the 
pulse rate is usually increased and other evidences of interference with 
the vital functions may be apparent. The abdominal organs are af- 
fected doubtless, in a similar manner, but symptoms due to this cause 
are not, as a rule, as clearly marked. 1 

Etiology — Relative Frequency. — Lateral curvature of the spine is 
one of the most common of deformities. In the past fifteen years, 
1885-1899, 3,252 cases were recorded in the Out-patient Department 

Fig. 79. 



Deformity of the thorax in scoliosis. (Hoffa.) 

of the Hospital for Ruptured and Crippled, a number only exceeded 
by that of bow legs, of which 5,030 cases were treated during the same 
period. 

The only statistics bearing upon the relative frequency of lateral 
curvature among children in general are those of Drachmann who 
found among 28,125 school children (16,789 boys, 11,386 girls) of 
Denmark 368 cases of scoliosis (1.3 per cent.). 

Sex. — Lateral curvature of the spine is far more common among fe- 
males than males. Of the 3,252 cases referred to 2,554 (78.5 per 
cent.) were in females and 698 (21.4 per cent.) were in males. 

The lowest percentage of males in any one of the fifteen years was 
14.8, the highest 25.1. This proportion of one male to four females 
is somewhat larger than in the smaller groups of cases reported by 
other observers. 

The unequal distribution of the deformity between the sexes is of 
great interest as bearing on the question of etiology ; especially so as 

1 Bachman, Die Veranderungen an den inneren Organen bei hochgradigen Skolio- 
sen und Kyphoskoliosen. Bibliotheca Medica Ab. D. 1, H. 4, 1900. 



ETIOLOG Y—STA. TISTICS. 131 

in the cases that develop in early childhood, sex appears to exercise 
practically no influence. It has been suggested that curvature of the 
spine in a girl is looked upon with more solicitude by the mother than 
is the same deformity in a boy, therefore more girls are brought for 
treatment. There may be some basis for this argument, for it is cer- 
tain that distortion of the lower extremities are considered of greater 
importance in male than in female children because of the concealment 
to be afforded by the skirts, if the deformity is not outgrown. But 
granting that statistics are somewhat unreliable, there can be no doubt 
but that this deformity is far more common among girls than boys and 
that the disproportion may be explained, in great part at least, by the 
differences in dress and in manner of life. 

Age. — 1,299 (39.9 per cent.) of the 3,252 patients referred to were 
less than fourteen years of age. 1,576 (48.4 per cent.) were between 
fourteen and twenty-one. 377 (1 1.6 per cent.) were more than twenty- 
one years of age. These statistics simply show the age of the patients 
at the time treatment was sought, and they are of little value as an 
indication of the age at which deformity might have been detected 
had it been looked for. 

There is no reason to suppose that lateral curvature of the spine 
differs in its etiology from similar deformities of other parts, except 
in so far as each region of the body is more or less susceptible to de- 
forming influences at one time than another. 

For example, rhachitic deformities of the upper extremities are 
practically never seen except in infancy, and they begin to correct 
themselves when the erect posture is assumed or at the very time when 
distortions of similar origin of the lower extremities develop. But 
when deformities of this class appear in later childhood or adolescence 
it may be assumed that, in many instances at least, the tendency 
toward the particular deformity, or even a slight degree of deformity, 
was acquired at an early age, that it remained latent until the condi- 
tions appeared which favored its further development. This point is 
illustrated by the statistics of Eulenburg of 1,000 cases of lateral 
curvature analyzed with reference to the inception of the deformity. 

Between birth and the sixth year 78 

Between the sixth and seventh years 216 

Between the seventh and tenth years 564 

Between the tenth and fourteenth years 107 

After the fourteenth year 35 

1,000 

It will be noted that but 142 (14.2 per cent.) of the patients were 
more than fourteen years of age as contrasted with the general statistics 
of the Hospital for Ruptured and Crippled, in which 60 per cent, were 
beyond this age. 

Dr. Walter Truslow, who for several years has had the immediate 
charge of the treatment of lateral curvature at the Hospital for Ruptured 
and Crippled, has prepared for me statistics of a number of the cases 



132 



LATERAL CURVATURE OF THE SPINE. 



under treatment by gymnastic exercises, which illustrate the same 
point. 

A. 



Age When Treatment was Begun. 



Age when examined. Males. 

4 years 



1 

4 

4 

4 

2 

3 

3 

4 

5 

3 



5 " 


6 " 


7 " 


8 " 


9 " 


10 " 


11 " 


12 " 


13 " 


14 " 


15 " 


16 " 


17 " 


18 " 


19 " 


20 " 


21 " 


23 " 


24 " 


32 " 



Females. 
1 
1 
1 

2 

7 

4 

7 
13 
16 
28 
25 
21 
14 

6 

2 

1 

1 

4 

1 

1 

1 



44 



157 



B. 



Age when the Deformity was Discovered. 

Males.' 
Congenital 2 



During infancy 19 

Between 3 and 6 years 16 

" 6 " 10 " 41 

" 10 " 13 " 62 

" 13 " 15 " 27 

Over 15 " 14 

Unknown 20 

20T 



32 



Total. 
1 

1 

2 

6 
11 

8 

9 
16 
19 
32 
30 
24 
22 

8 

3 

1 

1 

4 

1 

1 

1 



201 



Females. 



sex not stated. 




10 


6 


10 


31 


6 


56 


3 


24 


3 


11 



128 



But 44 of the 181 patients (22.6 per cent.) were more than 13 
years of age at the time when the deformity was first noticed, al- 
though nearly 50 per cent, were older when treatment was applied for. 
In the first table it will be noted that of the 38 patients who were 10 
years of age or less, 15 or about 40 per cent, of the number were 
males. In 25 of the 37 patients in whom the deformity is supposed 
to have developed at or before the sixth year, rhachitis was the ap- 
parent cause. 

Lateral curvature of the spine is one of the penalties of the erect 
posture, and the force of gravity must be considered both as a predis- 
posing and as an exciting cause of the deformity. 



ETIOLOGY. 133 

The more direct tendency of the force of gravity is to cause the body 
to fall forward and to increase the posterior curvature of the spine, but 
whenever there is a persistent inclination of the spine to one or the 
other side, this inclination is likely to be increased to deformity under 
favoring conditions. These favoring conditions would include general 
weakness from any cause ; overwork that may induce fatigue, and all 
factors, mechanical or otherwise, that may add to the difficulty of 
holding the trunk erect under the pressure of the superincumbent 
weight. 

Although it is not difficult to suggest the predisposing causes of 
lateral curvature, it is by no means as easy to point out the direct 
cause of the original inclination of the spine to one or the other side of 
the median line that is the first step toward fixed deformity. In a 
certain number of cases, however, the relation between cause and effect 
is sufficiently evident and these causes may be enumerated before con- 
sidering the larger class in which the etiology is more obscure. 

1. Lateral curvature, secondary to deformity of other parts. 

2. Static or mechanical deformity. 

3. Deformity secondary to disease of the nervous system. 

4. Deformity secondary to disease of the thoracic organs. 

5. Incidental deformity. 

6. Deformity due to occupation. 

7. Congenital deformity. 

8. Rhachitic deformity. 

1. Lateral Curvature Secondary to Deformity Else- 
where. — (a) Lateral curvature of the spine may be a compensatory 
effect of torticollis, either congenital or acquired. (6) It ma^#,be 
induced by distortion or inequality of the lower extremities. For 
example, fixed adduction of the thigh necessitates an upward tilting of 
the pelvis whenever the limb is brought into the normal line, whether 
the patient is standing, sitting or lying ; and this deformity when 
extreme, may induce lateral curvature even in bed-ridden patients. 
The same effect is sometimes observed in certain instances of inequality 
of the length of the lower extremities. In the erect posture the pelvis 
is tilted downward on one side, and this in turn necessitates a twist 
of the spine. 

2. Static Deformity. — Simple inequality of the limbs does not 
appear to be a common cause of fixed deformity because its influence 
ceases in the sitting and reclining postures, and because the inequality 
is so often compensated, if it be extreme, by walking on the toe or by 
raising the sole of the shoe. 

An increase in the length of a limb, such as may be caused by a 
fixed equinus of the foot, seems to have more influence in causing 
secondary deformity than does shortening, possibly because no attempt 
is made to compensate for the inequality. 

3. Lateral Curvature Secondary to Paralysis. — Lateral 
deformity of the spine may be caused indirectly by a number of dis- 
tinct diseases of the nervous system, but in this connection only one 



134 



LATERAL CURVATURE OF THE SPINE. 



need be considered — anterior poliomyelitis. This form of paralysis 
may act in several ways. It may induce deformity by distortion of a 
lower extremity or by inequality in the length of the limbs due to re- 
tardation of growth. It may predispose to deformity by the general 
weakness that it causes, or the trunk may be unbalanced by loss of 
function in one of the upper extremities, but the more extreme cases 
of deformity are caused by unilateral paralysis of the muscles of the 
trunk. As a result, the expansion of one side of the thorax is inter- 
fered with and the unaffected, 

or less affected, side taking on Fig. 81. 

increased activity, develops at 
the expense of the disabled part. 




Scoliosis following empyema at the age 
of 2 years. Present age 19 years. 



Scoliosis secondary to lumbar Pott's disease in early 
childhood. 



Thus the convexity of the curve is usually toward the sound side. 
4. Lateral Curvature Secondary to Disease within the 
Thoracic Walls. — The most common cause of deformity of this class 
is persistent empyema. The lung is primarily compressed by the 
effused fluid, and its function is finally impaired or abolished by the 
adhesions that form between it and the chest wall, as well as by the 
extension of the disease to its structure. As a result, the^ side of the 
chest is retracted while the function of the unaffected lung is increased. 



ETIOLOGY. 135 

(Fig. 80.) Thus, as in paralysis, the spine curves with the convexity 
toward the active side. 

Other affections of the lungs that interfere with the function of one 
side may induce lateral curvature, but the influence is less marked and 
direct than in empyema. 

5. Incidental Lateral Curvature. — Lateral curvature may be 
caused by direct injury or by disease of the spine, for example by frac- 
ture or by Pott's disease. (Fig. 81.) Distortion as a symptom of 
sacro- iliac disease, or the more marked deformity caused by sciatic or 
lumbar neuritis (Fig. 67), may if persistent finally induce slight per- 
manent deformity, but such cases hardly deserve special considera- 
tion. 

6. Lateral Curvature due to Occupation. — Lateral curvature 
of milder degree is incidental to certain occupations that require habit- 
ual inclination of the body. It is said to be very common among 
stone cutters, for example. Such deformity developing after the 
growth of the body has been attained, is, of course, of interest as 
throwing light upon the etiology of the ordinary form of lateral curva- 
ture. For if habitual occupation can thus change the contour of the 
developed spine, it is evident that similar postures, though far less con- 
stant, may influence the spine of a growing child, particularly in one 
predisposed to such distortion. 

7. Congenital Lateral Curvature. — Congenital scoliosis is 
uncommon (Fig. 82) in infants otherwise normal, and but few cases 
have come under my observation at an age sufficiently early to make 
the diagnosis absolutely certain. One case, in an otherwise well-formed 
male infant, was seen at the age of three months. There were well- 
marked lateral deviation and rotation in the dorsal region that had 
attracted attention soon after birth. A second case, in a female child, 
was seen at about the same age. The deformity was extreme, and 
contracted tissues on the concave side prevented the straightening of 
the spine. There was also an accompanying lumbar hernia. ' 

The first patient was cured by manipulation and posture before the 
completion of the first year ; the second, now six years of age, is still 
under treatment. A number of cases have been collected from liter- 
ature by Hirschberger. 1 

8. Rhachitic Lateral Curvature. — Rhachitis predisposes to 
deformity of all parts of the body by weakening the resistance of all 
the tissues. As is well known, the common deformities from this cause 
are the so-called rhachitic kyphosis that develops in the sitting child, 
and the distortions of the lower extremities in those who stand and 
walk. Lateral curvature of the spine sometimes accompanies the 
kyphosis in those who do not walk, or it may exist independently of 
it. The lateral inclination is induced doubtless by the manner of sit- 
ting or by the manner in which the child is supported on the mother's 
arm ; for at this period of rapid growth and increased susceptibility 
to deforming influences, even slight and temporary causes of this na- 

1 Beitrag zur Lehr der Angeboren Skoliosen, Zeits. f.Ortho. Chir., B. 7, H. 1, 1899. 



136 



LATERAL CURVATURE OF THE SPINE. 



ture may be sufficient to induce the distortion. (Fig. 83.) Again, when 
the child begins to walk, the tilting of the pelvis due to distortion of the 
limbs, for example to unilateral knock knee, may also serve to disturb 
the equilibrium of the body and thus to induce lateral distortion. 

How common rhachitic lateral curvature may be it is impossible 
to say, but it is probable that if all rhachitic infants and children 
were carefully examined, this deformity would be discovered in 
many instances in which its existence had not been suspected. 

In about 1 5 per cent, of the cases 
tabulated by Truslow the influence Fig. 83. 



Fig. 82. 





Congenital scoliosis. 



Rhachitic scoliosis. 



of one or more of the causes that have been enumerated seemed to be 
apparent, viz.: 

Congenital deformity 2 

Torticollis. 2 

Empyema 4 

Anterior poliomyelitis 3 

Inequality of the legs of more than \ inch 6 

Rhachitis 13 

Total 30 



ETIOLOG Y— POSTURES. 137 

In the remaining cases, 85 per cent., the direct cause of the de- 
formity was somewhat conjectural. 

Hereditary Influence. — By many writers the influence of heredity is 
considered an important factor in the etiology. That there is such an 
influence, predisposing to disease as well as to deformity, is undoubted, 
but it is very difficult to establish its connection with the ordinary cases. 
In 1 1 of 201 cases, lateral curvature was present in either the father 
or mother of the patient. And in 17 others a brother or sister of 
the patient was deformed in a similar manner. 

Occupation. — It is well known that occupation may induce de- 
formity in the adult and one looks naturally to occupation as a factor 
in the causation of lateral curvature in childhood. Occupation in 
this class implies school, and it may be assumed that the sitting pos- 
ture during school hours may cause fatigue especially if the chair is 
unsuitable or uncomfortable. (Figs. 84, 85.) Under the influence 
of fatigue an improper attitude is likely to be assumed which may 
become habitual, its character being influenced by the arrangement of 
the light or by the shape of the desk. "When a habit of posture is 
acquired it is likely to persist when the sitting posture is assumed else- 
where than at school and the greater liability of girls to the deformity 
may be explained in part by the fact that they sew, or read, or play on 
the piano, while boys are usually engaged during the same period in 
active exercise. 

In Truslow's tables the occupation is noted in 400 cases of lateral 
curvature ; also other habits that may have influenced the deformity. 

Occupation. 

School 285 

Factory 19 

Clerk 13 

Domestic 8 

Millinery, Dressmaking, etc 8 

Messenger 3 

Housewife 3 ' 

Teacher 2 

No occupation 59 

Total 400 

Posture. 

Weight on right foot 48 \ QR 

" left " 48j yD 

Carries books or baby on right arm 38 j „. 

" " " " " left " 36 j 

Sits at desk or work in faulty attitude 57 

Carries heavy load on one shoulder 2 

Excessive use of right arm in occupation 3 

Total 232 

The sitting posture is not the only one in which improper attitudes 
may be persistently assumed, in fact it has been suggested that the 
posture during sleep may influence the inclination of the body during 



138 



LATERAL CURVATURE OF THE SPINE. 
Fig. 84. 




Posture induced by improper desk and chair. (Scudder.) 
Fig. 85. 




Posture induced by improper chair. (Scudder. ) 



VARIETIES OF DEFORMITY. 139 

the hours of activity. But the sitting posture is the one in which the 
muscular support is most likely to be relaxed, and in which a tendency 
toward lateral inclination is most likely to be acquired, since children 
do not often retain a fixed attitude in the erect posture for any length 
of time. For this reason, inequality in the length of the limbs is of 
less importance as a cause of distortion than it would otherwise be. 
Bradford and Lovett record an observation of the attitudes of 67 
healthy adults undergoing a written examination. At the end of the 
second hour a lateral inclination of the body was evident in all, and 
in three-fourths of the number the general inclination of the body 
was to the right. In at least this proportion of the cases of lateral 
curvature the type of fixed deformity is to the left in the lumbar and 
to the right in the dorsal region, and it is natural to look upon the 
occupation as the important factor in determining the direction of the 
deformity. If it be assumed that the distortion is caused or influenced 
by the attitude assumed during school hours it would appear that the 
primary deformity should be more often of the lumbar region, for in 
the sitting posture the lumbar lordosis is lessened or lost, thus the 
bodies of the vertebrae in the lumbar region would be subjected to 
greater pressure than in the dorsal region, a pressure which might in- 
duce the changes in the bones that accompany deformity. 

The possibility of distinguishing the varieties of lateral curvature 
in which the primary distortion is lumbar from those in which it is 
dorsal, by the flattening of the dorsal kyphosis in the former, and its 
exaggeration in the latter instance, has been mentioned. 

Varieties of Deformity. — According to the statistics from various 
sources about three-fourths of the well-developed double curves of the 
spine are convex to the right in the dorsal and to the left in the lumbar 
region, and as the distortion of the thorax is the more noticeable of 
the two it usually classifies the deformity as right or left. The dorsal 
curvature may be either primary or secondary, and the relative frequency 
of the original deformity, whether lumbar or dorsal, is in doubt with 
the probabilities in favor of the former. 

Summary of Varieties of Deformity of the Spine under treatment 
1899-1900, at the Hospital for Ruptured and Crippled, tabulated by 
Dr. Truslow. 

1. Simple Antero-posterior Deformities. 

(a) Kyphosis 10 

Kypho-lordosis 1 

Lordosis 1 

12 

Round Shoulders. 

(b) Abducted scapulae 7 

Elevated scapula? 2 

~9 Total, 21 



140 LATERAL CURVATURE OF THE SPINE. 

2. Antero-posterior Abnormalities most Marked, but Accompanied 
by Lateral Deviation. 

(a) With single lateral curve 14 

(b) With double lateral curve 16 

(c) With triple lateral curve 7 

37 

3. Rotation most Marked, but Accompanied by Lateral 

Deviation. 

(a) With double lateral curves 22 

(b) With triple lateral curves 8 

30 

4. Lateral Deviation most Marked, Direction of the Curves. 
Right Dorsal, Left Lumbar Type. 

(a) Single lateral curve 22 

(b) Double lateral curve 71 

(c) Triple lateral curve 6 

99 

Left Dorsal, Right Lumbar Type. 

(a) Single lateral curve 3 

(b) Double lateral curve 8 

(c) Triple lateral curve 3 

14 Total, 201 

It will be noted that in 21 instances antero-posterior deformity ex- 
isted without lateral deviation, and that in 37 instances it was accom- 
panied by lateral deviation. In the remaining 144 cases, rotation was 
more marked than lateral deviation in 30 cases, and lateral deviation 
more marked than rotation in 113. In the entire number of cases in 
which lateral deviation was present it was single in 39 cases, double 
in 117 cases, triple in 24 cases. 

In 373 cases of lateral curvature tabulated by Liining and Schul- 
thess the deformity was as follows i 1 

Left. Right. Total. 

Total scoliosis (single curve affect- 
ing the entire spine) 79 16 95 

Lumbar scoliosis (single curve lim- 
ited to the lumbar region) 14 3 17 

Lumbo-dorsal scoliosis (single curve 

limited to lumbo-dorsal region)... 49 60 109 

Complicated scoliosis. 

(a) Right dorsal, left lumbar 123 

(b) Left dorsal, right lumbar..... 29 152 

171 202 373 

It will be noted that a very large proportion of these cases were in 
the early stage of deformity as indicated by the absence of compen- 
satory curves; that in 82 per cent, of the 112 cases in which the 
curve was general or most marked in the lumbar region, the inclina- 
tion was to the left, and of the complicated or more fully developed 
1 Zeits. fur Orth. Chir., Bd. V. 



DIAGNOSIS. 141 

cases in which the curve was double, 80 per cent, were of the right 
dorsal left lumbar type. 

Symptoms. — In the large proportion of cases the first symptom of 
the affection is the deformity. This is often discovered by the dress- 
maker at the age when the clothing is made to fit the figure more closely. 
In certain instances the deformity may be preceded or accompanied by 
pain. This was present to a greater or less degree in about one-quarter 
of the cases examined by Truslow. Pain may be simply the discom- 
fort or the dragging sensation of fatigue, usually referred to the lumbar 
region, or it may be severe and neuralgic in type. The latter variety 
is more common in the cases in which the deformity is extreme. It is 
said to be the result of pressure on nerves, but this is doubtful as it 
is often referred to the convex as well as to the concave side. There 
are also more general symptoms of a neurasthenic or hysterical nature 
that may be due in part to the deformity and in part to the debility 
of which it may be a result or accompaniment. For it must be borne 
in mind that lateral curvature is, in many instances, symptomatic of 
debility, as is shown by the fact that it is often accompanied by other 
deformities, particularly by the weak foot. In many instances symp- 
toms of weakness and awkwardness precede the deformity. Truslow 
states that in a large proportion of the cases investigated the patients 
had been distinctly less active than their companions, that they did 
not enjoy exercise and were inclined to lead sedentary lives. Tesch- 
ner 1 has called attention to the same peculiarity. He states that the 
patients are often indifferent, apathetic and lazy. He has noted also 
a peculiar lack of coordination and muscular control as a common 
symptom. These symptoms apply particularly to the period of adoles- 
cence, the time of rapid growth and instability, when any latent de- 
formity or weakness is likely to be exaggerated. In younger subjects 
such symptoms are far less marked, or are absent. In the cases in 
which the deformity is extreme, symptoms due to interference with 
the respiratory and circulatory apparatus, or caused by the displace- 
ment of the abdominal organs, may be present. These are, however, 
rather unusual. 

Diagnosis. Posture. — Lateral curvature of the spine is a sim- 
ple deformity unaccompanied by the symptoms of disease. When the 
patient stands with the back and hips bare, the inclination of the body 
to one or the other side and the general want of symmetry, are usually 
apparent, even in the earliest stage of the affection. For, as has been 
stated, the habitual assumption of a certain posture precedes fixed 
changes in and about the spine, and this posture will appear when the 
patient is asked to stand in the usual manner. If the inclination of 
the body is toward the left (Fig. 69), the left arm will hang in close 
apposition to its lateral border, while on the right side an interval 
will appear between the arm and the trunk. If there be a slight lum- 
bar curve to the left (Fig. 71), the right iliac crest will be accentuated. 

1 Medical Record, Dec. 16, 1893. 



142 LATERAL CURVATURE OF THE SPINE. 

The curvature in the dorsal region makes one shoulder higher than 
the other (Fig. 83), the scapula on the affected side projects and the 
distance between its posterior border and the median line is increased. 
Rotation of the spine is shown by the fullness or projection of one side 
accompanied by a corresponding flatness on the other. This is more 
noticeable when the patient bends the body forward so that the hori- 
zontal plane of the back is brought into view. (Fig. 70.) Corre- 
sponding changes, though of a less marked degree, appear on the ante- 
rior surface of the body, for example the apparent diminution in the 
size of the mamma on the side opposite the convexity of the posterior 
curve and its relative depression or elevation will usually attract 
attention. 

It seems probable that a change in the antero-posterior contour of 
the spine precedes, in many instances, the lateral deviation. Thus a 
general droop of the body associated with round shoulders and a flat- 
tening of the chest, may be regarded as a predisposing cause or an 
early symptom of more serious deformity. 

Mobility. — As has been stated, it may be assumed that habitual 
posture precedes actual deformity ; habitual posture implies disuse of 
certain other attitudes and motions, thus limitation of the normal flexi- 
bility of the spine may be considered as one of the earliest signs of 
progressive deformity. The test of the motion of the different regions 
of the spine is therefore a necessary part of the examination. To test 
the motion in the lumbar region, one fixes the pelvis with the hands 
while the patient sways the body in the four directions and rotates it 
from side to side. It is suggested by Bradford and Lovett that direct 
lateral flexibility may be tested by placing blocks of wood under one 
foot, until the limit of flexion is reached, as shown by the inability of 
the patient to hold the elevated limb in the extended position. The ex- 
periment is then repeated on the opposite side. The flexibility of the 
upper part of the trunk may be tested by fixing the part below with 
the hands while the patient flexes, extends and rotates the body. It 
is important also to test the range of motion at the shoulder joints. 
The normal individual should be able to hold the arms extended di- 
rectly above the head without increasing the lumbar lordosis. In 
many instances, however, it will be found that there is a marked re- 
striction of this motion, in fact such restriction is almost always an ac- 
companiment of so-called round shoulders. 

The height and weight, the circumference and the expansion of the 
chest should be investigated, and a test of the muscular strength, not 
only of the muscles of the trunk but of the members as well, is of ad- 
vantage as throwing light on the etiology and indicating the general 
line of treatment. 

Record. — The most reliable of the graphic records to be used in 
connection with the history are photographs. The patient may stand 
behind a thread screen (Fig. 86) in the habitual attitude. The spin- 
ous processes, the iliac crests and the angles of the scapulae having 
been marked with the flesh pencil, the exact amount of lateral devia- 



PROGNOSIS. 



143 



Fig. 86. 



tion of the trunk will be shown. The rotation may be indicated also 
by photographing the patient in the recumbent posture. 

The rotation of the spine is the most importaut indication of de- 
formity. This may be recorded with sufficient accuracy by taking 
direct tracings of half the trunk at 
fixed points by means of a lead or 
zinc tape while the patient lies in 
the recumbent posture. 

At the Hospital for Ruptured 
and Crippled, the shadow of the 
trunk cast by an electric light at 
a fixed distance is traced upon a 
large sheet of paper. Upon this 
outline the position of the more im- 
portant landmarks is indicated. 
The degree of rotation is shown 
by transverse tracings and the line 
of the spinous processes is ascer- 
tained by applying a broad strip of 
adhesive plaster to the back upon 
which the tip of each spinous proc- 
ess is marked. 

Prognosis. — In the development 
of lateral curvature there is doubt- 
less a preliminary or predisposing 
stage, a stage of progression and a 
stage of arrest. All deformities of 
this class are more likely to progress 
during the growing period. They 
are likely to become stationary 
when the period of growth is com- 
pleted. Thus the prognosis is worse 
when the deformity begins at an 
early age than when it first appears 
in adolescence, especially if treatment is neglected or if it is inefficient. 
" For example, some of the most extreme cases are caused by rhachitis, 
in which the deformity appearing in infancy or early childhood in- 
creases with the growth of the child. 

If the causes of the deformity are such that they operate to check 
the equal development of the affected part, the prognosis is even more 
directly influenced by the age of the patient. For example, empyema, 
even if the lung is irreparably damaged, does not cause appreciable 
deformity in the adult, but in childhood the functional activity and the 
growth of the side of the thorax are checked, in addition to the direct 
effect of the adhesions and contractions due to the disease, thus the 
deformity is likely to be progressive in spite of the treatment. The 
same is true of paralytic deformity. In the ordinary type of lateral 
curvature in the adolescent girl, the prognosis is influenced of course, 




The thread screen. From the Boston Children's 
Hospital Report. 



144 LATERAL CURVATURE OF THE SPINE. 

by the general condition of the patient and by the character of the 
occupation. As far as the local deformity is concerned, the prognosis 
as regards improvement or cure depends in great degree upon the fixed 
changes that have taken place, and upon the degree of voluntary and 
involuntary rectification that is possible. In some instances the dis- 
tortion of the body as apparent in the habitual posture may be consider- 
able, yet the fixed deformity may be very slight, while in other in- 
stances the fixed rotation of the spine may be marked although the 
lateral distortion is hardly noticeable. 

A single curve is more amenable to treatment than is a double or 
triple distortion, because it indicates an earlier stage of deformity and 
because the treatment may be more effective when applied to one de- 
formity than to several. If, however, the single curve is fixed, the 
appearance of a secondary or compensatory curve at another part of 
the spine is probable, in spite of preventive treatment. 

In the majority of cases, as has been stated, fixed deformity of the 
spine is already present when the patient is brought for treatment. 
This fixed deformity might be overcome doubtless in certain cases, and 
complete cure might be obtained, were all the conditions favorable. 
But in the ordinary sense a cure means the relief of symptoms, the 
checking of the progress of the deformity and the restoration of the 
general symmetry of the trunk. Such a cure may be obtained in most 
instances. The deformity of the spine becomes symmetrically divided 
on either side of the median line, the changes incident to maturity, 
particularly the increased amount of adipose tissue, serve to conceal 
the irregularities of the outline, and the history of the distortion is 
completed. 

In certain instances, particularly in well-marked cases, the deform- 
ity may increase in adult life and even in old age ; and in this class 
also the symptoms of discomfort and actual pain may be troublesome 
throughout life, especially in the overworked and debilitated class. 
The symptoms directly incident to the compression and distortion of 
the internal organs, have been mentioned. 

The great majority of cases that develop or that are discovered in 
adolescence, progress for a time and come to an end on the cessation of 
growth, causing finally no symptoms other than the loss of symmetry 
that may be more or less perfectly concealed by the art of the dress- 
maker and by the corset. 

It would appear then that lateral curvature of the spine is always of 
sufficient gravity to merit treatment and supervision until its cure or 
arrest is assured. If its discovery leads to active efforts to improve 
the general condition and to avoid unhealthful influences, it may even 
be of benefit to the patient. 

Lateral curvature in a young child is of far greater importance be- 
cause of the probability of an increase of deformity. Extreme de- 
formity is always a source of weakness and usually of discomfort to the 
patient. Incipient deformity may be cured and cure is not impossible 
even when deformity is more advanced, but in this more than in any 



RECAPITULATION. 145 

other postural deformity, absolute cure implies early diagnosis and 
prevention, rather than the correction of fixed distortion. 

Recapitulation. — It seems probable that in the ordinary type of lat- 
eral curvature of the spine, the first step is a change in the relation of 
the bodies of the vertebrae to one another ; that a persistent lateral in- 
clination and rotation of the anterior part of the column precedes the 
lateral inclination of the trunk which first calls attention to the de- 
formity. This postural distortion becomes fixed by accommodative 
changes in the muscles and other tissues about the spine, and finally 
it is confirmed by changes in the shape of the vertebral bodies and by 
the general changes in the trunk as a whole. Thus if one might ob- 
serve the inception and development of lateral curvature of the com- 
mon type he would note, first, that the trunk was more often flexed 
to one side than to the other, and that this attitude gradually became 
habitual. Lateral inclination of the trunk necessitates of course lateral 
deviation and rotation of the bodies of the vertebra? and the habitual 
assumption of such a posture implies disuse of other postures and thus 
disuse of normal motion. 

Disuse of motion in any direction is followed by diminished power 
in the inactive muscles, and as has been stated habitual deformity is fol- 
lowed by accommodative changes to a greater or less degree in the 
various tissues whose functions have been changed or modified. 

Thus the progress of the deformity would be shown : 

1. By the habitual assumption of an attitude simulating deformity. 

2. By limitation of motion in the directions opposed to the habitual 
attitudes. 

3. By fixed lateral deviation of the spine accompanied by rotation or 
twisting of the column. 

One rarely has the opportunity to note the development of lateral 
curvature and when patients are brought for treatment fixed deformity 
is usually present. It is extremely difficult to entirely overcome fixed 
distortion, while it is comparatively easy to correct simple postural 
deformity in which the secondary changes are absent or but slightly 
advanced. On this account it is customary to divide lateral curvature 
into two classes, the true and the false, or to speak of rotary lateral 
'curvature as distinct from lateral curvature. Thus the term true or 
rotary curvature would be limited to those cases in which the changes 
are fixed and in which cure is practically impossible, while false or 
simple or postural lateral curvature would include the early or cur- 
able class. But as the two forms are simply stages in the same proc- 
ess it would seem preferable to speak of the incipient and the later 
stages of lateral curvature, or of reducible or irreducible deformity, 
the distinctions that are made in classifying distortions of similar 
origin elsewhere. 

This point of view is of advantage because it relieves the subject of 

much of the obscurity that has resulted from this arbitrary division. 

It emphasizes the fact also that the habitual assumption of an improper 

attitude that simulates deformity is the first step toward permanent dis- 

10 



146 



LATERAL CURVATURE OF THE SPINE. 



tortion, particularly in individuals who are by inheritance or by con- 
stitutional tendency or by occupation predisposed to such deformity. 

The Prevention of Deformity. — Prevention would include the 
avoidance of all the predisposing or exciting causes of weakness as 
well as of deformity. These it is hardly necessary to enumerate. 

The first and most important preventive measure is the discovery 
of deformity or the tendency to deformity, at a time when it may be 
checked or cured. To discover deformity at this period of its devel- 
opment, one must look for it, and deformity in this sense would in- 
clude not only fixed distortion, but improper attitudes and postures of 
every variety as well. 

The importance of the attitude which is habitually assumed during 
occupation has been mentioned. Therefore, the provision of proper 
desks and seats for school children is a very essential part of preventive 
treatment. 

The seat of the chair should be deep enough to support the thighs, 
yet it should not interfere with flexion at the knees. It should be of 
such height as to allow the feet to rest firmly on the floor, and it 



Fig. 87. 




Adjustable school desks and seats. Scheiber and Klein. (R^dard.) 

should be inclined slightly backward. The back of the chair should 
extend to about the level of the shoulders, it should be inclined 
slightly backward, but arched somewhat forward in the lumbar region 
in order to conform to the normal lordosis when the child sits in the 
erect posture. The desk should be as close to the body as is possible, 
so that the child need not lean far forward when reading or writing. 
The height of the desk should be slightly less than the level of the 
elbows when the child sits erect, and the inclination should be suffi- 
cient to hold the book at the proper distance from the eyes. The 
vertical handwriting is of advantage in that the children are taught 
to face the desk squarely, as contrasted with the lateral twist of the 
body, the usual attitude for writing. (Figs. 87 and 88.) 



PRINCIPLES OF TREATMENT. 



147 



Treatment. — The treatment of rotary lateral curvature of the spine 
does not differ in principle from the treatment of any other weakness 
or deformity, but the application of this principle is much more diffi- 
cult here than elsewhere, and the results are far less definite and satis- 
factory. This explains doubtless the apparently opposing theories and 
methods of treatment that are still advocated. 

A brief account then of the rules of treatment as applied to weak- 
ness in general and of the exceptions that must be made in their appli- 
cation to curvature of the spine may be illustrated by comparing this 
deformity with another of similar causation. 

One may take for comparison the weak foot, since the foot corre- 
sponds more nearly to the spine than does a simple joint, because of the 
number of bones of which it is 
made up. In the treatment of 
the weak foot one must first over- 
come all restrictions to passive 
motion, even by force if this be 
necessary. One next endeavors 
to strengthen the muscles that 
support the foot, by appropri- 
ate exercises, particularly those 
whose action is opposed to the 
habitual deformity. The avoid- 
ance of improper attitudes and of 
over-fatigue that favor deformity 
is also essential. Finally, if per- 
sistent deformity makes it evi- 
dent that the voluntary or natural 
efforts of the patient are ineffi- 
cient, a brace is employed to sup- 
port the foot in proper position 
in order to aid the weakened 
muscles and to hold the joints in 
the normal position in which 
they may work to advantage. 
"Under these conditions one 
would expect an immediate relief 
of discomfort and a progressive transformation of the internal struc- 
ture of the foot, which in favorable cases would lead to complete cure 
of the deformity and of the weakness as well. 

The principles of the treatment of any variety of weakness not di- 
rectly induced by disease are then : 

1. To overcome all restriction to passive motion. 

2. To strengthen the weakened muscles, especially those whose ac- 
tion is opposed to habitual deformity. 

3. To insist on the avoidance of over -fatigue and improper postures. 

4. To support the weak part, if necessary, by a brace. 

In applying these principles to the treatment of the distorted spine 




Adjustable school seat. (Miller and Stone.) 



148 LATERAL CURVATURE OF THE SPINE. 

the first step, the removal of restriction to passive motion in all direc- 
tions, may be accomplished unless the deformity is of long standing, 
but this is difficult because of the variety of muscles and other 
tissues that may have become involved, and because the bodies of the 
vertebrae lying within the trunk, of which the distortion is always 
greater than the spinous processes, can be only indirectly affected by 
voluntary or by passive movements. The cultivation of the muscular 
system and particularly of those muscles whose action is opposed to 
the habitual deformity, is the second indication in treatment. As ap- 
plied to the treatment of the weak foot in which the adductor and ex- 
tensor muscles are at fault, this treatment is simple, but as applied to 
the trunk it is difficult because there are in nearly all developed cases two 
curves, the one primary and the other secondary ; in direction directly 
opposed to one another. These opposite deformities are supplied in 
great part by the same muscles and it is difficult to straighten the con- 
vexity of one curve without at the same time increasing the concavity 
of the other. The third principle in treatment is the avoidance of 
predisposing attitudes and of overwork. This again may be more 
easily applied to the treatment of the weak foot ; first because it is 
relieved from strain when the sitting posture is assumed and because 
active use, as in walking, may be utilized as an exercise for strengthen- 
ing the muscles. But the muscles of the trunk are not exercised to 
any extent in ordinary walking, which is for many individuals the 
only form of activity, nor is the spine relieved from weight when the 
patient is seated. On the contrary it is in this restful attitude that 
the deformities of the spine are usually most marked. Thus only in 
the recumbent attitude is the spine entirely relieved from strain, and 
even at such times the deformities may be favored by the habitual atti- 
tudes of the patient. 

Support of the weakened part by braces. The weak foot can be 
supported by a brace which in no way interferes with its activity, but 
which on the contrary makes movements free and normal by holding 
the bones in their proper relation to one another. But in the treat- 
ment of the spine the conditions are quite different, since the back can- 
not be supported without at the same time practically fixing it in one 
position, restraining its normal motion and compressing the muscles of 
the trunk. In other words the action of the support and the action 
of the muscles, instead of aiding one another, are almost directly op- 
posed to one another ; and finally no brace applied to the trunk is 
efficient, for while it may prevent the excessive lateral deformity it can 
exercise no direct action in overcoming the rotation of the spinal column. 
For these reasons braces except as temporary supports in cases under 
corrective treatment and in the hopeless class, are less in favor than in 
former times. 

This comparative method of exposition has been adopted in order 
to demonstrate the fact that it is not the difficulty in formulating prin- 
ciples but the difficulty in applying them that makes the therapeutics of 
rotary lateral curvature of the spine perplexing. It is only by recog- 



PRINCIPLES OF TREATMENT. 149 

nizing the limitations of all systems of treatment as applied to this 
particular deformity and the necessity for selection and combination 
of methods that may be applicable to the particular case under treat- 
ment that one may arrive at satisfactory conclusions. Thus methods 
must be modified by the age of the patient and by a variety of other 
circumstances. 

For example, in the treatment of rhachitic scoliosis in a young child 
one cannot count upon the voluntary assistance of the patient, therefore 
treatment by simple gymnastic exercises is impracticable. In this class 
of cases forcible correction of the deformity and retention by the use of 
apparatus, combined with massage, and the removal of superincumbent 
weight, would be the treatment of selection ; for at this age the trunk 
is flexible and the deformity may be overcome, in part at least, by 
forcible manipulation. By progressive reduction of the distortion, 
followed by fixation of the trunk in the improved position one may 
expect at this period of rapid growth to induce a transformation of 
the deformed vertebral bodies to an approximation at least of the nor- 
mal. In this class of cases the possibility of correcting the underlying 
deformity of the bones which must almost inevitably increase with the 
growth of the patient would quite outweigh the disadvantage of de- 
priving the muscles of their normal stimulus during the corrective 
period of treatment. 

In the ordinary type of scoliosis in older subjects, particularly if the 
distortion is moderate in degree and the changes in the bones but slight, 
one would expect to attain the best result by gymnastic training and 
by regulation of the postures. 

The advisability of a change of occupation has been mentioned. It 
is probable that if the patient with incipient or even pronounced curva- 
ture of the spine were removed from school, were transferred to the 
country where during the succeeding years of childhood and adoles- 
cence much of the time might be passed in active exercise in the open 
air, the final result would compare very favorably with that attained 
by active treatment under less favorable surroundings. Such complete 
change of occupation and scene is of course impracticable in most in- 
stances. Lateral curvature of the spine is not a serious disease, it 
is simply an insidious distortion which rarely causes more than com- 
paratively slight discomfort. It is usually overlooked in the incipient 
stage when it might be checked or cured, and w r hen the deformity 
finally attracts attention it is usually no longer amenable to correction. 
Under these circumstances, with the uncertainty that exists as to the 
ultimate prognosis, the tediousness of treatment Avhich cannot offer the 
assurance of definite cure, it is not strange that the affection is not one for 
the treatment of which any considerable sacrifice is considered essential. 

A third class of cases would include the fixed deformity in older 
subjects, many of whom are obliged to assume in their occupations atti- 
tudes that predispose to deformity. In this class the use of a support 
to relieve discomfort and to prevent exaggerated distortion, may be 
indicated. 



150 LATERAL CURVATURE OF THE SPIXE. 

Thus there are three classes or types of scoliosis in which distinct 
methods of treatment may be indicated. 

1. Curvatures in very young children, in which forcible correction 
and fixation would be the preliminary treatment, in the hope of cor- 
recting the deformity of the bones and curing the distortion. 

2. The milder degrees of deformity for which treatment by exercises 
and if possible by favoring postures is the treatment of selection. 

3. The third class would include fixed deformity in older subjects, 
as well as those cases caused by disease ; as for example by paralysis, by 
empyema and the like, for which constant support might be indicated. 

As a rule, however, no such distinction can be drawn. The treat- 
ment by exercises and by postures applies to all cases except in very 
early childhood, while support is indicated in a far more limited class. 

Posture and Exercises. — Whatever may have been the original 
cause of the distortion of the spine and whatever may be its degree it 
is more marked when the patient is fatigued. Fatigue in the normal 
individual is shown by the increase in the normal antero-posterior 
curves ; fatigue in the deformed subject causes an increase in the path- 
ological curves. It requires far more muscular effort to hold the 
deformed spine in the best possible attitude than to hold the normal 
spine in the erect posture. Motion in the normal spine is as free in one 
direction as in another and it simply requires a proper balancing of 
the muscular force to hold it in the median line. Under the influence 
of fatigue it has no more inclination toward one side than the other 
unless the occupation or the attitude of the patient influences it. But 
when there is a fixed deformity, to overcome which, even in part, 
requires the conscious effort of the patient, it is evident that on the 
relaxation of this effort the spine will sink back into the habitual 
posture. The more confirmed the deformity the greater must be the 
effort to overcome it, and the more rapidly will fatigue be manifest. 
Fatigue, or rather the relaxation of conscious muscular effort, is fa- 
vored by attitudes that do not require the balancing action of the 
muscles. For example, the sitting posture during school hours favors 
deformity, while the constant alternation of postures in work or play 
that requires muscular activity opposes it. Thus the selection of oc- 
cupations, or at least the restriction of the time passed in inactive 
postures, is an essential part of treatment. 

As improper attitudes are favored by weakness of muscles and as 
the maintenance of the best possible position requires a greater expen- 
diture of muscular force than is required in the normal individual, 
the strengthening of all the muscles of the body, and particularly of 
those of the back, by gymnastic exercises, even beyond the normal 
standard, is the most important indication in treatment. 

One of the most effective systems of treatment of lateral curvature 
is that advocated by Teschner, of New York. On the theory that 
lateral curvature is induced or that its development is favored by a 
general lack of muscular strength and lack of muscular control and 
coordination Teschner urges the necessity of the systematic cultivation 



EXERCISES. 



151 



of all the muscles of the body as well as those of the trunk, the part 
particularly at fault. He also insists upon the importance of exercis- 
ing each muscular group to the point of fatigue on the theory that a 
muscle cannot be developed to its full capacity unless it is thoroughly 
fatigued by uninterrupted automatic contractions and relaxations. The 
term automatic implies that the patient shall be so thoroughly trained 
in the rhythmical movements that they require no thought for their 
performance. Thus ease and grace may replace awkwardness and in- 
coordination. 

The system advocated by Teschner is modified from one taught by 
Attilla, a " trainer of strong men." It consists of a series of exer- 
cises with light dumb-bells and it is followed by so-called heavy work. 



Fig. 89. 



Fir. 90. 



Fig. 91. 






The exercises are designed for systematic cultivation of all the mus- 
cles of the body, the heavy work more directly for the correction of 
the deformity of the spine. 

f General Exercises. — The exercises should be performed before a mir- 
ror, the patient being clad in a close-fitting rowing suit so that the atti- 
tudes may be constantly observed by the patient and by the instructor. 
The greatest attention is paid to the perfection of the alternating 
movements of the limbs in order that they may become in time purely 
automatic in character. During the performance of the exercises the 
patient holds himself in the best possible position. 

These exercises were described and illustrated by Teschner in the 
Annals of Surgery for August, 1895, from which they are, with his per- 
mission, reproduced. 

" A pair of dumb-bells, weighing from one-half to five pounds each, 
according to the ability of the patient, is used in a series of twenty-six 
exercises. 



152 



LATERAL CURVATURE OF THE SPINE. 



The Exercises. — The patient stands erect, the heels together, the 
toes apart, the knees thoroughly extended, the abdomen retracted, the 




Fig. 93. 




chest high, the head well poised, and the patient looking intently and 
sharply into his or her own eyes in the mirror, the lips being evenly, 
but not too firmly, closed, and the facial muscles in repose. The pa- 



Fig. 94. 



Fig. 95. 



n <r 








tient should breathe easily and regularly while exercising. (Figs. 89 
and 90.) 



EXERCISES. 



153 



" 1. The upper extremities are fully extended downward, the fore- 
arms supinated, the elbows remaining close to the sides of the body, 
and the upper arms being fixed ; the fore- 
arms are alternately and automatically fully Fig. 97. 





flexed and extended, the wrists and entire body being fixed and im- 
movable. Twenty to fifty times. (Fig. 91.) 

" 2. The same position and exercise, except that the forearms a re 



Fig. 98. 



Fig. 99. 





154 



LATERAL CURVATURE OF THE SPINE. 



fully pronated, and remain so during alternate flexion and extension. 
Twenty to fifty times. (Fig. 92.) 

" 3. Both bells over the shoulders, the arms abducted at right angles 
to the body and in the same vertical and horizontal planes, the fore- 
arms fully flexed upon the arms, and the wrists fully flexed upon the 
forearms. The forearms and wrists are then alternately and automat- 
ically extended and flexed. Ten to twenty times. (Fig. 93.) 

" 4. The same position and exercise, except that both upper extrem- 
ities are flexed and extended at the same time. Five to fifteen times. 
(Fig. 94.) _ . 

" 5. Both upper extremities fully extended forward on a level with 
the shoulders, the dorsum of the hands outward. They are then 
fully and forcibly abducted on a horizontal plane, the patient at the 
same time raising body upon the toes, and are then permitted to re- 



Fig. 100. 



Fig. 101. 





cede to the original position, the body resting on the toes and heels, 
the elbows and wrists still rigid, the bells not being permitted to 
touch as they approximate each other. Five to ten times. (Figs. 95 
and 96.) 

" 6. Bells in the position of exercises No. 3 and No. 4. The arms 
are fullv extended alternately above the head. Ten to twenty times. 
(Fig. 97.) 

" 7. Bells in front of the thighs, forearms pronated, and bells alter- 
nately raised to the level of the shoulders, the elbows and wrists be- 
ing fixed. Ten to twenty times. (Fig. 98.) 

" 8. The arms abducted at right angles to the body, the bells rotated 
rapidly and forcibly forward and backward, the elbows being fixed. 
Five to ten times. (Fig. 99.) 



EXERCISES. 



155 



" 9. The arms abducted at right angles to the body, the thumbs upon 
one ball of each bell, the hands circumducted forward from above 
downward, the ball upon which the thumbs rest describing circles, the 
elbows and shoulders being fixed. Five to ten times. (Fig. 100.) 

" 10. The same as ~No. 9, the hands being circumducted backward. 
Five to ten times. (Fig. 100.) 

"11. The bells to the side. Right face upon left heel, then placing 
the left foot at right angles to right foot opposite the arch, the knees 
slightly flexed, the right hand at waist-line against the body, the bell 



Fig. 102. 




being perpendicular. Second part of motion : strike from the shoulder 
to level of the face, advancing a step upon the left foot, rapidly ex- 
tending the right thigh and leg, the right foot being fixed upon the 
floor, and quickly back to position. Ten to fifteen times. (Figs. 101 
and 102.) 

"12. Exactly the reverse of No. 11. Ten to fifteen times. 

" 13. Bells extending above the head, palmar surfaces looking for- 
ward, bending down to the floor, the knees remaining extended, and 
return. Five to fifteen times. (Figs. 103 and 104.) 

" 14. Bells downward at the sides, raising and dropping the shoul- 
ders. Ten to twenty times. (Fig. 105.) 

" 15. Bells downward at the sides, flexing the spine laterally, first to 
the right and then to the left. Ten to twenty times. (Fig. 106.) 

"16. Both arms extended forward to about forty-five degrees and ab- 
ducted at about the same angle, then forcibly crossed in front of the 



156 



LATERAL CURVATURE OF THE SPINE. 



chest, causing the pectoral muscles to contract vigorously, the elbows 
and wrists being fixed, and then back to the original position. Five 
to twenty times, alternating the right and left hands above. (Fig. 107.) 




Fig. 106. 




" 17. Bells at the sides, palmar surfaces looking forward. Extend 
arms backward in a vertical plane as forcibly as possible, holding them 
rigid in the fully extended position for a few moments, and then re- 



Fig. 107. 



Fig. 108. 





EXERCISES. 



157 



turning the bells to the sides. Five to fifteen times. (Figs. 108 
and 109.) 

" 18. Bells to the sides. Raise the body upon the toes and sink to 
original position. Ten to twenty times. (Fig. 110.) 

" 19. Same position. Raise the toes as far as possible from the floor, 



Fig. 109. 



Fig. 110. 





the body remaining erect. Ten to twenty times. (Fig. 111.) 

" 20. Same position. The patient squats, abducting the knees and 
resting upon the toes, the heels being raised, the trunk perfectly erect, 
then resuming first position. Five to twenty times. (Fig. 112.) 



Fig. 111. 




Fig. 112. 




158 



LATERAL CURVATURE OF THE SPINE. 



"21. Same position. Standing upon left foot. Flexing the right 
thigh to a right angle to the body extending the knee and ankle fully. 
The patient squats on the left ham, the left heel remaining on the floor,. 



Fig. 114. 



Fig. 113. 





and then resumes the first position. Two to five times. (Fig. 113.) 
" 22. The same standing upon the right foot. Two to five times. 
" 23. The same position. Alternately and forcibly flexing the thighs 



Fig. 115. 



Fig. 116. 



■ I 




EXERCISES. 



159 



and legs, causing the knees to touch the shoulders. Ten to twenty 
times. (Fig. 114.) 

Fig. 117. 

si: f 



' .VI 

1 

-' •*• 




" 24. The same position as in No. 21, extending the right lower ex- 
tremity, the right bell inside the thigh, the right foot moved in a cir- 



Fig. 118. 




Scoliosis of an advanced type accompanied by dyspnoea and cyanosis. (Teschner.) 



160 



LATERAL CURVATURE OF THE SPINE. 



cle on a horizontal plane to complete extension backward, and resum- 
ing the first position. Two to five times. (Figs, 115 and 116.) 

" 25. The same as No. 24, standing upon the right foot. Two to 
five times. (Figs. 115 and 116.) 

" 26. The patient lying supine upon the floor, the lower extremities 
fully extended, the bells resting upon the chest, then raising the trunk 

Fig. 119. 




The same patient swinging 30-pound bell, showing the muscular development. (Teschnek. ) 



to the sitting position, the lower extremities remaining extended, and 
the eyes being fixed upon the ceiling, and returning to the original 
position, touching the back of the head only on the floor, thus the 
hyperextension of the spine is maintained. Five to twenty times. 
(Fig. 117.) 

"When the patient has become proficient in these exercises, they 
should be done at home every morning and evening. 



EXERCISES. 



161 



" The Heavy Work. — Bells, weighing from five to eighty pounds 
each, and steel bars and bar-bells, weighing from twenty-six to over 
one hundred and eleven pounds, are used in different ways. Bells are 
pushed from the shoulders above the head alternately as often as the 
patient is able. (Fig. 119.)" 

" The patient is instructed to swing a heavy bell with one hand from 



Fig. 120. 



Fig. 121. 





The patient pushing 25-pound bells 
the right arm up. (Teschner.) 



The patient pushing 25-pound bells 
the left arm up. (Teschner. ) 



the floor above the head and down again, the elbow and wrist being 
fixed, and the motion repeated as often as possible in a systematic 
manner ; then with the other hand the same number of times, and 
later with both. This exerts all the extensor muscles from the toes to 
the head in rapid succession. 

" When a heavy bell is pushed or swung above the head on the side 
11 



162 LATERAL CURVATURE OF THE SPINE. 

opposite the scoliosis, the action of the back muscles, to sustain the 
weight and equilibrium, is such as to cause the curved spine to ap- 
proximate a straight line. (Fig. 121.) A similar result is produced 
when a heavy weight is held by the side of the erect body on the 
scoliotic side, the arm being at full length. 

" When a heavy bar is raised above the head with both hands, the 
patient must fix the eyes upon the middle of the bar to maintain an 
equilibrium. This necessitates the bending of the head backward, the 
straightening and hyperextending of the spine, and consequently cor- 
recting a faulty position with a weight superimposed. The heavier 
the weight put above the head, whether with one hand or with two, the 
more the patient must exert himself or herself to attain and maintain 
a correct or an improved attitude in order to sustain the equilibrium. 
(By an improved attitude I mean the greatest amount of correction of 
the deviation of the spine that the fixation of a deformity will allow 
of.) Hence, the greater the weight, the more forcible the actions of 
the muscles become, and the greater the temporary reduction of a de- 
formity. It is by means of frequent and forcible temporary reductions 
of deformities, by voluntary muscular action, that we can hope to im- 
prove, and do improve, those cases which are amenable to any form of 
active treatment. 

" When a patient, lying supine upon the floor, raises a heavy bar 
above the head so that the arms are perpendicular to the floor, the 
weight of the bar, the position and weight of the body, and the action 
of the muscles tend to broaden the entire back and shoulders, and a 
slow downward movement tends to widen the entire chest, and most 
markedly at the shoulders. The frequent repetition of the upward 
and downward movement plays an important part in the rapid devel- 
opment of the chest and back. Pushing the bells above the head, 
swinging them with each hand separately and with both hands to- 
gether, raising a bar above the head, standing and lying down, and the 
exercises before enumerated, constitute one day's work. 

" As the amount of work performed by a patient depends upon the 
last previous record of that patient, that record must be improved upon 
at each succeeding visit, unless there be a good and sufficient reason to 
the contrary. Most patients can well stand three treatments a week. 
(Vide table.) In mild, habitual cases improvement in deportment is 
noticed by the patients' relatives and friends and by the patients them- 
selves within the first two weeks. In those cases two months' treatment 
usually suffices to effect a complete cure. In the more severe cases it is 
not and can not be expected to attain such rapid results, but a certain 
appreciable improvement is effected, and the amount of improvement 
depends upon the persistent continuance of the treatment. When there 
is a fixed rotation of long standing, with bony and ligamentous changes, 
the prospects are not so good ; but even in those cases considerable im- 
provement will be evident. 

" Patients are not permitted to wear supports of any kind, not even 
corsets. They should not exercise until at least two hours after a 



EXERCISES. 



163 



meal, nor when menstruating. The general health is improved by the 
exercises ; the patients gain in height and weight. The girths and 
breadth measurements, chest depth, strength tests, and lung capacity 
are generally increased, and the depth of the abdomen is usually de- 
creased. In some cases, especially those of undersized patients, the in- 
crease in height is very rapid, and it is certainly more than the increase 
by ordinary growth. There were marked cases of flat foot which were 
benefited. The flat feet became shorter through the exercises by the 
increase in depth of the inner arches." 



Record of the Work 



Performed by a Girl 14 Years of Age. 
(Teschner.) 







6 






6 






Date. 


8« 


s 

03 


£ X < 
> o 

CO -«J 




s 

Pi 


Fifty-Pound Bar Above 
the Head. 




« 




W 


M 








1895. 


Bells. 


Two 
10-lb. Bells. 


One 

15-lb. Bell. 

R.— L. 


Two 
15-lb. Bells. 


Two 

20-lb. Bells. 


Standing. 


Lying Down. 


April 6. 
" 9. 


3 lbs. 














tt 


ioo" 


10— io 


5 




Instructed. 


Instructed. 
5 


" 11. 


it 


150 


25—25 


15 


"io" 


2 






2 15-lb. 


1 20-lb. 














bells. 


bell. 










" 13. 


it 


50 


25—25 


25 


12 


5 


10 


" 16. 


tt 


54 


30—30 


35 


18 


7 


12 


" .18. 


it 


60 


35—35 

1 25-lb. 

bell. 


40 

2 20-lb. 

bells. 


20 


7 


15 


" 20. 


it 


70 


20—20 


20 


30 


10 


15 


" 25. 


a 


90 


22—22 


25 


33 


15 


16 


" 27. 


it 


100 


35—35 


30 


50 


17 


20 


" 30. 


a 


110 


50—50 


35 


60 


20 


22 


May 2. 


it 


120 


60—60 
1 30-lb. 


36 


70 
2 25-lb. 


20 


25 








bell. 




bells. 


64-lb. bar. 


64-lb. bar. 


4. 


(t 


140 


20—20 


40 


25 


5 


10 


7. 


a 


150 


25—25 


45 


30 


7 


12 


" 14. 


a 


160 


27—27 


50 


34 


9 


13 


" 16. 


a 


170 


30—30 


55 


40 


10 


14 



This method combines the forcible correction of deformity by means 
of the " heavy work " with muscle building. It has the merit also of 
making an immediate mental impression upon the patient which no 
other system can make ; for if the patient does not " strain every 
nerve/' he must certainly exercise every muscle, to preserve the 
equilibrium while supporting the heavy weights, and this mental im- 
pression is undoubtedly one of the important elements in successful 
treatment. 

The system has the disadvantage, if disadvantage it may be called, 
of making class work impossible, for the patient must be under con- 
stant supervision, not only that he may be urged to the limit of his 
capacity, but that over-strain may be avoided as well. 



164 LATERAL] CURVATURE OF THE SPINE. 

It might appear from the description that the danger of over-work 
is great, but in a long series of cases, some of which were compli- 
cated by defects of the heart and lungs, no unfavorable symptoms have 
been observed by Teschner. The system is, however, one that can 
only be practiced by a physician. 

Another system of exercises is that followed at the Hospital for 
Ruptured and Crippled. Dr. Truslow has been kind enough to out- 
line for me some of the more important exercises and to illustrate them 
with the photographs that are reproduced here. 

The objects of the treatment are : (1) To overcome the patient's 
faulty habits of posture by the repeated purposeful assumption of 
proper postures ; in other words, to counteract the deformity habit 
by training the mental and muscular perception of symmetry. (2) 
To stimulate and to strengthen the weakened muscles, particularly 
those muscular groups that are especially concerned in overcoming the 
deformities, and which, for the present purpose, may be considered as 
weak. 

For convenience of description the exercises are divided into two 
classes: (1) Self correction ; (2) Muscle building. 

Self Correction, Postures. — The first exercises (a and 6) in self 
correction are for the purpose of overcoming the antero-posterior de- 
formities that usually accompany lateral deviation of the spine. 

(a) Head Bending Backward. — In this exercise the chin is not tilted 
upward, but, the head being held level, the neck is drawn directly 
backward until the cervical and upper part of the dorsal segments of 
the spine are completely extended. Thus by increasing the distance 
between the points of attachment of the sterno-mastoids and the 
scaleni, strong traction is made upon these muscles with the effect of 
elevating the upper part of the thorax, an important feature in the 
exercise. 

(6) Trunk Bending Forward and Trunk Raising. — The patient stands 
in the erect posture with the spine extended and the chest expanded 
as in the previous exercise. The trunk is then bent forward (similar 
to Fig. 127), the only motion being at the hip joints. The trunk is 
then raised again to the former position, care being taken to keep the 
hips farther back than the chest. In both flexion and extension the 
spine must be rigidly held in the corrected attitude and there must 
be no motion at the knees. There is, of course, a movement corre- 
sponding to extension at the ankle joints when the legs and buttocks 
are thrown backwards to compensate for the forward bending of the 
body. The object of this exercise is to train the patient to keep the 
hips back and the chest forward. 

The other exercises in self correction are for the purpose of over- 
coming lateral deviation of the spine, the right dorsal, left lumbar 
curve, with the high right shoulder and the prominent left hip, being 
taken as a type. (Fig. 122.) 

This series is arranged in a progression, and each one must be 
learned before the next in order is attempted. 



EXERCISES. 



165 



(c) Left Neck Firm. — The left hand is placed behind the neck, the 
left shoulder is raised and the left elbow is held well back. This pos- 



Fig. 122. 




Typical lateral curvature. Eight dorsal. Left lumbar. 

ture impresses upon the patient the necessity of approximating the 
left shoulder and the neck. (Fig. 123.) 



166 



LATERAL CURVATURE OF THE SPINE. 



(d) Body Inclination to the Left. — This is a most important posture ; 
it is intended to correct mechanically the faulty inclination to the right 
and to overcome the upper curve by traction on its concavity. The 
patient holding the arm in the first position is instructed to stretch 
well out with the left elbow, rotating upward and abducting the left 



Fig. 123. 




Left neck firm. 



scapula as much as possible. This puts upon the stretch the rhom- 
boidei and the lower half of the trapezius of the left side, thus mak- 
ing strong traction upon their points of attachment in the dorsal con- 
cavity. At the same time the patient is directed to sway the pelvis 
to the right. This usually requires assistance at first, for it brings 



EXERCISES. 



167 



into action certain deep back muscles, over which one has ordinarily 
but little control. The shoulders must be kept level and the proper 
relation of the head and neck to the left shoulder must not be dis- 
turbed in this forced stretch to the left. (Fig. 124.) 

(e) Chest Pressing with the Right Hand. — The patient holding the 
left arm in the first position presses the right hand firmly against the 

Fig. 124. 




Body inclination to the left. 



dorsal convexity. This posture may be employed to advantage if 
there is a long right dorsal curve, when it is an efficient aid to the 
left-sided pull of the two former exercises. 

(/) Right Neck Finn. — The right hand is placed behind the neck, 
without, however, disturbing the improved position induced by the 
first exercises. With both hands placed behind the head, the arms 



168 



LATERAL CURVATURE OF THE SPINE. 



being in a symmetrical position, there is better mechanical fixation of 
the head, neck and upper part of the trunk during the next exercise. 
(Fig. 125.) 

(g) Left Hip Twisting Backward. — In posture (d) the pelvis was 
swayed slightly to the right ; it is now twisted slightly backward on 
the left side to overcome the twist in the lumbar spine which usually 
throws this side of the pelvis somewhat forward. This correcting 

Fig. 125. 




Right neck firm. 



motion should be carried out in the lower dorsal and lumbar seg- 
ments and it should not affect the attitude of the remainder of the 
trunk. 

(li) Left Oblique Stride Standing. — The pelvic twist and right-sided 
sway being rigidly maintained, the left foot is placed about two foot- 
lengths forward and a little outward. Upon this leg the greater part 
of the weight of the body is now supported. This allows a slight 
downward tilt of the pelvis to the right, and lessens the left lumbar 
convexity. (Fig. 126.) The positions, attained by the progressive 



EXERCISES. 



169 



exercises to this point, being maintained, the patient continues with 
(i) Trunk Bending Forward. — In this posture, motion takes place 



Fig. 126. 




Left oblique stride standing. 

in the hip joints only, as in the first exercise. This exercise further 
emphasizes the symmetrical position of the head and neck, the left- 



170 



LATERAL CURVATURE OF 1HE SPINE. 



sided inclination of the upper half of the trunk, the right-sided incli- 
nation of the lower half, the twist and downward tilt of the pelvis. 
(Fig. 127.) The return to the improved standing position should be 
made in this order: (1) Trunk raising; (2) Replacement of the left foot; 
(3) Return of both arms to the sides. This is done slowly and care- 
fully by the patient, who attempts to maintain the improved posture. 

Fig. 127. 




Trunk bending forward. 



The postures constitute a progression which cannot be learned in less 
than seven treatments ; often much more time is required. As each 
part is learned, it should be practiced at home until the next treatment, 
when a new posture is added, if it appears that progress can be made. 



EXERCISES. 171 

These successive postures are in reality exercises in that it requires 
constant muscular effort to retain them, but they are not exercises in 
the sense of repeated alternations of position. The series is simply an 
elaboration of what is called the keynote posture. The raising of the 
left elbow, for example, makes it easier for the patient to overcome the 
distortion of the upper part of the spine ; it also instructs him in the 
manner of holding the spine in the improved position after the arm is 
placed by the side. The same is true of all the postures ; each one 
suggests and makes correction easier, and after sufficient practice the 
patient should be able to assume the corrected position without plac- 
ing the arm or the leg in the preliminary attitude. Thus the suc- 
cessive postures are, as it were, letters, which, placed together one by 
one, make a complete word, or the best possible position that the 
patient can assume. At first the patient must use the letters and 
slowly spell out the corrected attitude, but after the muscles have been 
educated by the repeated assumption of each posture, and when the 
perception of symmetry has been acquired, the corrected attitude may 
be assumed at will, and, in part, at least, instinctively retained at all 
times. 

Muscle Building, Exercises. — In the treatment of lateral curva- 
ture one aims to strengthen : 

1. The posterior cervical muscles. 

2. The dorsal and lumbar muscles. 

3. The muscles of vertebro-scapula attachment. 

4. The abdominal muscles. 

5. The thigh and leg muscles. 

6. The chest-expanding muscles. 

The following exercises have been selected as best adapted for this 
purpose. Each one should be performed five or more times according 
to the strength of the patient. 

(a) Opposite Standing, Head Bending Backward, Resisted. — The 
patient stands before a wall or a shoulder-high horizontal bar on which 
the hands are placed with the arms extended. The head is bent for- 
ward and is then forced backward, the latter movement being resisted 
by the hand of the surgeon. This exercise is designed to strengthen 
the posterior cervical muscles. 

(b) Opposite Bend Standing, Trunk Raising, Resisted. — The patient 
stands with the upper part of the thighs in contact with a table or 
horizontal bar. The hands are placed behind the neck and the body 
is bent forward on the hip joints as in the first exercise. The surgeon 
standing behind places his right hand over the posterior dorsal prom- 
inence and his left over the lumbar projection. The patient then 
raises the trunk to the erect position against the combined resistance. 
(Fig. 128.) With a little practice the surgeon learns to give an out- 
ward twisting motion to his hands while resisting, Avhich tends to un- 
twist the spinal rotations. When the dorsal rotation to the right is 
marked this untwisting may be facilitated by encircling the patient's 
chest with the left hand while with the right, strong forward and out- 



172 



LATERAL CURVATURE OF THE SPINE. 



ward pressure is made as the patient raises the body. This exercise is 

for the purpose of developing the muscles of the erector spina? group. 

(c) Prone Lying, Head and Shoulder Raising " The Seal." — The 



Fig. 128. 




Opposite bend standing." Trunk raising resisted. 



patient lies upon a table or upon the floor, and raises the head and 
chest — " looks at the ceiling/' Progression is made in the increased 
leverage of arm -weight transference. 

1. With the hands on the backs of the thighs. 



EXERCISES. 



173 




174 LATERAL CURVATURE OF THE SPINE. 

2. With the left hand behind the neck and the right hand on the 
back of the thigh. 

3. With both hands behind the neck, and with the elbows well out 
and back. 

4. " Swimming." The arm motions of swimming, in three counts. 
This exercise is to strengthen the muscles of the back from the head 
to the pelvis. 

(d) Prone Lying, "Diving" — The patient lies upon a table, the 
trunk and pelvis projecting beyond its edge, the limbs being fixed by 
a strap or by the weight of another person. The body is then bent 
downward and is raised again to the horizontal position. (Fig. 129.) 
In this exercise, assistance will be required at first. Progression is 
made by transference of arm weights, as in the former exercise, thus : 

1. With the hands on the hips. 

2. With the arms stretched out at right angles to the body. 

3. With the hands behind the neck. 

4. With the arms extended in the line of the body. 

This exercise is for the purpose of strengthening all the muscles of 
the back. 

(e) Prone Lying, Leg Raising. — The patient, lying in the prone pos- 
ture upon the floor or table, lifts the limbs (over-extends) alternately, 
the raised leg being held perfectly straight. When the left thigh is 
extended, as much as the ilio-femoral ligament will allow, the left side 
of the pelvis is tilted upward also, thus untwisting the lumbar spine. 
Progression in this exercise is made as follows : 

1. Alternate leg raising, unresisted. 

2. Alternate leg raising, resisted. 

3. The leg motions of swimming, in three counts. 

In this exercise the entire lower extremities must project beyond the 
supporting table. The exercises are for the purpose of strengthening 
the lumbar muscles and the extensors of the thigh. 

(/) Opposite Sitting, Backward Bending of the Trunk. — The patient 
is seated upon a bench, and the feet are fastened to the floor. The 
trunk being held in a position of complete extension is bent slowly 
backward, motion being at the hip joint only. Progression. 

1. With the hands behind the hips. 

2. With the left hand behind the neck, the right hand on the hip. 

3. With both hands behind the neck. 

4. With both arms extended upward. 

At first the body is bent backwards about forty-five degrees, later 
until the head touches the floor. This exercise is to strengthen the 
abdominal muscles. 

(g) The Horizontal Bar. " Pull-ups." — The patient hangs by the 
hands and is assisted to " chin the bar." The body is then allowed to 
sink slowly back into the former position, the elbows are held well 
back, and the patient is instructed to bear as much of the weight as is 
possible with the left arm and shoulder. This exercise corrects the 
dorsal curve by means of muscular activity, and the lumbar curve by 



THE REMOVAL OF SUPEBINCU3IBENT WEIGHT. 175 

the weight of the suspended pelvis and limbs. The muscles used are 
those with vertebro-scapula attachment. 

(h) Left Leg Standing, Pelvis Tilting. — The patient stands upon the 
edge of a bench, supporting the weight on the left leg, the right leg 
being suspended beyond the side of the bench. While the head and 
trunk are kept in the corrected position, the pelvis is made to tilt 
sharply downward on the right, by lowering the right leg, while the 
left is kept perfectly stiff. This has the effect of straightening the 
lumbar curve. 

(i) Left Leg " Hopping." — Both hands are placed behind the neck 
and the weight is supported entirely upon the ball of the left foot. In 
this attitude the patient hops ten or more times. This exercise, like 
the last, tends to straighten the spine and to strengthen the muscles of 
the left leg, which are often somewhat weakened from disuse. 

(j) Respiratory, Half Reclining, Arm Extensions and Flexions, Re- 
sisted. — The patient sits in a chair with an inclined back, or lies upon 
a low table with hard pillows under the mid-dorsal region, so that the 
upper dorsal and cervical segments of the spine must be over-extended. 
The arms are stretched upward and backward, and the hands are 
grasped by the surgeon, who stands behind and resists the patient's 
downward pull. With the upward stretch of the arms and pull by the 
surgeon, the patient inhales forcibly. With the downward pull against 
resistance, the patient exhales forcibly. This exercise is made in the 
rhythm of slow breathing. 

When the patient has been thoroughly instructed in self correction 
and in the exercises for muscle building, general gymnastics for sys- 
tematic motor training, may be given effectively in groups of fifteen or 
twenty pupils. For such exercises the " days order " of the Swedish 
Educational Gymnastics is preferred. 

These two systems of treatment by gymnastics have been selected as 
the most practicable of the many that have been devised. It may be 
stated that any treatment that makes the spine more flexible, that 
overcomes faulty attitudes and that strengthens the muscles, must be 
of benefit to the patient, the degree of benefit corresponding to the per- 
sistence and energy of the pupil and the instructor, rather than to any 
particular theory on which such treatment is based. 

The Removal of Superincumbent Weight. — The removal of 
superincumbent weight by the assumption of the reclining posture 
whenever the patient is fatigued, is an important adjunct in the treat- 
ment of a certain class of cases. 

Self Suspension. — Self suspension, by means of the halter and 
pulley is of service in overcoming secondary contractions of the tissu es, 
and thus it aids in the correction of deformity. It is often efficacious also 
in relieving the discomfort that is sometimes a troublesome symptom 
when the distortion is extreme. While the patient is suspended, forcible 
manual correction of the deformity can be applied to advantage. 

Suspension from the horizontal bar acts in a similar manner, although 
it is less effective than when the traction is made upon the entire spine. 



176 



LATERAL CURVATURE OF THE SPINE. 



In this form of suspension, the bar should be oblique in direction, the 
high side for the low shoulder. Thus a passive " keynote " is in- 
duced while the patient is suspended. Exercises in this position, for 
example, flexion and extension of the thighs, swaying the trunk from 
side to side, " chinning " the bar and the like, are useful. 

The Use of Braces or Other Supports. — In the treatment of the 
ordinary type of lateral curvature, 
when there is an opportunity for Fig. 131. 

proper gymnastic training, support 

not indicated. There are, how- 



is 



ever, exceptional cases in which the 
deformity habit is so persistent, and 



Fig. 130. 





Self suspension illustrating the effect of traction in lessening deformity. (Gibney.) 

in which the voluntary efforts of the patient to assume a better 
attitude are so ineffective, that support may be employed for a time 
with advantage. 

The best support is a plaster corset applied while the patient is sus- 



FORCIBLE CORRECTION OF DEFORMITY. 



Ill 



pended. This may be removed at night and when the exercises are 
performed. Even while the corset is worn, the patient should endeavor 
to improve upon the attitude which it enforces, by assuming the key- 
note position and by flexing and extending the trunk on the hips. 

When the deformity is dependent upon irremediable injury or dis- 
ease, for example, anterior poliomyelitis or empyema, some form of 
brace may be employed to prevent excessive lateral deviation of the 
trunk ; and in cases of fixed deformity in older subjects, especially if 
the patient is obliged to follow a fatiguing occupation, a support may 
be indicated, because of symptoms of discomfort or pain. 

Support is employed primarily with the aim of preventing an increase 
of deformity and to relieve symptoms incidental to the deformity. It 
may, in some degree, also serve as a corrective appliance. If it holds 
the spine in the extended position or induces lordosis, it may, by reliev- 

Fig. 132. 




The Knight spinal brace. 



ing the bodies of the vertebrse in part from the deforming influence of 
superincumbent weight, allow for slight untwisting of the rotation and 
a corresponding transformation of the distorted parts. On this princi- 
ple a light steel brace after the Taylor model may be as effective as 
any of the more complicated appliances, as was suggested many years 
ago by Judson. Corsets of other material than plaster, for example, 
of paper, or of aluminium, as suggested by Phelps, may be employed 
when the deformity is fixed and when no change in the position or 
size of the trunk is to be expected. The Knight brace, when care- 
fully adjusted, appears to meet the requirements fairly well, and when 
less support is needed, an ordinary corset strengthened by light steels 
may be sufficient. 

Forcible Correction of Deformity. — In the treatment by gymnastic 
12 



178 



LATERAL CUBVATUBE OF THE SPINE. 



Fig. 133. 



exercises the patients are supposed to overcome by voluntary effort, as 
far as is possible, the secondary accommodative contractions of the soft 
parts that prevent the correction of the deformity. But in many in- 
stances the voluntary correction of deformity may be supplemented 
with advantage by the employment of force. For example, the patient 
may use the weight of the body as a means of correction by forcibly 
flexing the trunk over a padded bar (Fig. 138) and a variety of similar 

postures, either active or passive, 
with or without suspension may 
be utilized with the same object. 
Corrective force applied by the 
hands, the patient's trunk being 
flexed and rotated in the directions 
opposed to the deformities, al- 
though the most effective method, 
is the most fatiguing, and ma- 
chines have been constructed with 
the aim of applying the force in 
similar manner. This is illustrated 
by the appliance of Hoffa, which 
has been modified by Schede and 
others. In this machine the pa- 
tient is suspended, the hips are 
fixed and the pressure screws are 
applied upon the convexities of the 
double curve, with the aim of un- 
twisting the spine. The correction 
is maintained for fifteen minutes or 
longer, and it is then followed by 
the regular exercises of the day. 
(Fig. 133.) 

The Forcible Correction of Defor- 
mity Combined with Fixation. — 
Forcible correction and fixation is 
the treatment of selection for resis- 
tant lateral curvature in early 
childhood, because one cannot com- 
mand the cooperation of the patient 
in maintaining the proper attitude, 
and because the rapid growth at 
this age, which favors the increase of the deformity is equally favorable 
to its cure if the static conditions can be changed. 

For example, one treats the severe rhachitic kyphosis of infancy by 
fixation in the horizontal position, and by daily manual correction of 
the deformity. And in the treatment of older children, in whom pos- 
terior or lateral deformity is fixed, one is justified in using the same 
method for its relief and cure that would be employed in the treatment 
of Pott's disease. In this class the plaster of Paris jacket, applied 




Forcible correction by means of the modified 
Hoffa appliance. (Bradford and Brackett. ) 



FORCIBLE CORRECTION OF DEFORMITY. 179 

while the trunk is held in the best possible position, is the treatment of se- 
lection, a treatment that should be continued until the deformity is cured 
or until further rectification by this means is found to be impossible. 

The most convenient method of applying the jacket is by means of 
the ordinary suspension apparatus. The back having been carefully 
padded at the points of pressure, the patient is suspended and while 
traction and manual corrective force are exerted the plaster bandages 
are applied. In this correction two points are of especial importance, 
to attain as much extension or over-correction as possible and to sway 
the entire body in the direction opposite to the habitual inclination. 
By over-extension one removes the weight in part from the vertebral 
bodies that are primarily deformed, and by lateral correction one 
endeavors to change the relation of the weight to the distorted part. 
This improved position must be carefully maintained by the hands 

Fig. 134. 




Congenital scoliosis. After treatment for three years by forcible correction and fixation by plaster 
jackets. Showing the disappearance of the rotation. 

until the plaster bandages have become firm. The jackets may be 
changed at intervals of a month or more and at each application one 
attempts to improve upon the former position. 

The jacket is used in preference to the corset because it holds the spine 
more perfectly. It is of course a disadvantage to employ such restraint, 
but as has been stated the prognosis in fixed rotary lateral curvature in 
a young child is, as regards ultimate deformity, extremely unfavorable, 
and one is justified therefore in sacrificing muscular activity in order that 
the original deformity of the bones may be remedied. As an illustra- 
tion of persistence in this method of treatment it may be stated that it 
was continued by me for nearly three years in one case of extreme 
scoliosis of congenital origin with most gratifying success. (Fig. 134.) 

The jackets may be applied also in the horizontal position, traction 
being exerted upon the arms and legs, combined with manual pressure 



180 LATERAL CURVATURE OF THE SPINE. 

on the trunk, somewhat after the manner of the Calot method of cor- 
rection of the deformity of Pott's disease. 

When the deformity has been overcome, or when the continuation 
of the treatment seems undesirable, the jacket may be replaced by a 
corset, which may be removed for daily massage and for exercises. This 
may be finally discarded when the muscular strength has been regained. 

As has been stated, forcible correction and fixation is essentially a 
treatment of deformity in early childhood. But in certain instances, 
when, for example, the deformity is extreme or is increasing rapidly, 
it may be employed in adolescence. In the treatment of this class of 
cases the plaster jacket is usually applied while the patient is fixed in 
the best possible position by means of some form of pressure apparatus, 
as is illustrated in Fig. 133. 

Forcible correction of deformity under anaesthesia has little to recom- 
mend it, since whatever deformity can be corrected with anaesthesia 
can be corrected without it. 

The Volkmann Seat. — In cases of primary lumbar curvature, or 
when the secondary curve of this region is pronounced, the attitude 
may be improved and the deformity may be corrected in part by seat- 
ing the patient on an inclined plane, the high side beneath the low hip, 
thus lessening the convexity of the curve. 

The High Shoe. — The same object may be attained in the erect 
posture by the use of a higher heel, or heel and sole. The elevation 
may be from a half inch to an inch and a-quarter, the amount being 
regulated by its effect upon the contour of the trunk. 

Posture and Support During Kecumbency. — The attitudes 
habitually assumed during recumbency should be investigated. The 
bed should be provided with a hard mattress and a low pillow, and 
the patient should be encouraged to lie upon the side in an attitude 
which opposes the deformity, or upon the back. The rectification in- 
duced by such an attitude may be still further increased by the use of 
a hard pillow beneath the convexity or beneath the back, and in cer- 
tain instances the Barwell sling may be employed with advantage. 

General Treatment. — The importance of improving the general 
condition of the patient by regulation of the diet, by cold baths and 
by active exercise in the open air is self-evident. The strain upon the 
back should be lessened by providing proper seats and by limiting the 
time passed in passive attitudes, and by lessening, as far as is possible, 
the restraint of the clothing. These precautions are of almost equal 
importance with the active treatment. 

The Duration of Treatment. — The duration of treatment depends of 
course upon the character of the deformity and upon its causes. In 
the ordinary type of adolescent scoliosis, the duration of active treatment 
is usually from three to six months. In this time the muscles may be 
so strengthened and the necessity for constant attention to the attitudes 
may be so impressed upon the patient, that the simple exercises which 
may be performed at home, may be sufficient. It is well, however, if pos- 
sible, to keep the patient under supervision during the period of growth. 



CHAPTER IV. 

DEFORMITIES OF THE SPINE.— Continued. DEFORMI- 
TIES OF THE CHEST. THE FUNCTIONAL 
PATHOGENESIS OF DEFORMITY. 



Variations in the Contour of the Spine. 

One recognizes a certain contour of the spine as normal, but there 
are variations from this type which, within certain limits, can hardly 



be classed as abnormal. 



Two of these have been mentioned, the round 



Fig. 135. 



Fig. 136. 




The hollow round back. (Hoffa.) 



The round back. (Hoffa. ) 



back (Fig. 136) in which there is a general forward droop most 
marked at the shoulders ; and the hollow round back (Fig. 135) in 



182 



DEFORMITIES OF THE SPINE. 



which the dorsal kyphosis and the lumbar lordosis are somewhat ex- 
aggerated. A third type is the flat back (Fig. 71), in which there is 
neither a lumbar lordosis nor a dorsal kyphosis. In the marked cases 
there is an actual prominence in the lumbar region, while the scapulae 
project backward from the flattened dorsal spine. This type of back 
is probably the result, in many instances, of a rhachitic kyphosis 
which was most prominent in the lumbar region. The flat back and 
the round back predisposed to lateral curvature. 



Antero -Posterior Deformities of the Spine. 

Kyphosis. — As has been stated in the chapter on Pott's disease, 
the spine is practically straight at birth. If during the early weeks of 
life an infant be placed in the sitting posture the head falls forward and 

the spine bends into a long 
Fig. 137. posterior curve, the posture 

of weakness. The normal 
anterior convexity of the 
cervical section is estab- 
lished when the gain in mus- 
cular power enables the in- 
fant to hold the head erect, 
and that of the lumbar re- 
gion when the pelvis is tilted 
downward by the extension 
of the thighs in the erect 
posture. 

In the erect posture the 
constant tendency of the 
weight of the head and of the 
thoracic and abdominal or- 
gans is to draw the spine for- 
ward and to reestablish the 
original posterior curve. 
This tendency is resisted by 
the action of the posterior 
muscles of the trunk. 
Whenever, therefore, the 
muscular power is lessened 
or the body is over-burdened 
or whenever the spine is 
weakened by disease the ten- 
dency toward the original 
curve of weakness, becomes 
apparent. (Fig. 137.) Thus the causes of an abnormal increase in the 
posterior curvature of the spine are very numerous. It is, as has been 
stated, the characteristic attitude of weakness as is illustrated in infancy 
and in old age. It is one of the common occupation deformities of adult 




Marked posterior curvature of the spine apparently in- 
duced by weakness incidental to illness. 



KYPHOSIS. 



183 



life ; it is a common postural deformity of childhood and adolescence. 
It may be induced by a variety of diseases that lessen the resistance of 
the spine or that interfere with its function. For example, by rhachitis, 
spondylitis deformans, osteitis deformans, Pott's disease and affections 
of a similar nature. 

The kyphosis of rhachitis is most marked in the lower region, that 
of spondylitis deformans may involve the entire spine, while the simple 
postural curvature is most marked in the upper dorsal region. In a 
number of the postural deformities the increase in the dorsal kyphosis 



Fig. 138. 



Fig. 139. 





Exercises for the correction of posterior curvatures of the spine. (Hoffa.) 

is balanced by an increased lordosis and in this form there is simply an 
exaggeration of the normal curves of the spine, the " hollow round" 
back. ^ In other instances there is a general forward droop of the trunk 
in which the lumbar lordosis may be lessened ; this form is more com- 
mon in childhood, the " round " back. 

The forms of kyphosis that are the direct result of disease have been 
described elsewhere. Postural kyphosis, " round shoulders," is one of 
the common deformities, and in childhood its etiology is similar to that 
of lateral curvature, of which it may be a predisposing cause. Round 
shoulders and the accompanying flat chest may be induced also by ob- 



184 



DEFORMITIES OF THE SPINE. 



Fig. 140. 



structions in the respiratory passages, such as enlarged tonsils, adenoids 
and the like or by bronchitis or heart disease. Another predisposing 
cause is clothing that prevents the full expansion of the chest and the 
extension of the arms, and even the weight of clothing suspended from 
the shoulders may be a factor in the etiology. These possible contribu- 
ting causes should be investigated in all cases of this type. 

Treatment. — The treatment is similar to that of lateral curvature. 
The assumption of the military attitude with the head erect, the chin 
depressed, the shoulders thrown back, the chest expanded and the 
abdomen retracted, should be encouraged. And those exercises that 

expand the chest and that 
strengthen the muscles of the 
upper part of the spine, are 
especially important. (Such 
exercises are illustrated by 
Figs. 95, 96, 103, 104, 109, 
110, 119, 125,127,129, 138 
and 139.) If the range of 
vertical extension of the arms 
is limited, this restriction must 
be overcome before the defor- 
mity of the spine can be per- 
manently improved. In well- 
marked cases the patient 
should be encouraged to read 
or study in the prone posture 
in this attitude in which the 
trunk must be'supported upon 
the elbows and the head held 
backward, there is necessarily 
an involuntary correction of 
the deformity. In certain 
instances, a light spinal brace 
may be employed during the 
hours when the passive atti- 
tude must be assumed, but as a rule artificial support should be avoi- 
ded. (Fig. 140.) Shoulder braces, so-called, are useless. Clothing 
should not restrict the movements of the arms or trunk, and as little 
weight as possible should be suspended from the shoulders. 

Lordosis. — Lordosis, or an abnormal hollowness of the back, is far 
less common than kyphosis. It is not a simple postural deformity, 
but it is usually secondary to disease or deformity either of the spine 
or of the adjoining members. For example, lordosis may be induced 
by flexion contraction of the thighs ; it is a symptom of congenital 
displacement of the hips ; it is sometimes a result of certain forms of 
nervous disease, in which, because of muscular weakness, the body is 
swayed backward to retain the balance, as in pseudo-hypertrophic pa- 
ralysis. Lordosis in the lumbar region may be a compensation for a 




Tempered steel uprights for round shoulders. (Brad- 
ford AND LOVETT. ) 



ETIOLOGY. 



185 



Fig. 141. 



kyphosis in the upper segment. It is caused directly by spondylolis- 
thesis. It may be a congenital deformity and it is said to be a pecu- 
liarity of contortionists. 

Treatment. — As lordosis is usually a secondary deformity its treat- 
ment would be included in the treatment of its causes. In some in- 
stances the discomfort which is usually present when the deformity is 
well marked may be relieved by a proper corset sufficiently strong to 
support the back. 

Congenital Elevation of the Scapula. 

Synonym. — SprengePs Deformity. 

Sprengel's deformity is a congenital elevation of the scapula above 
the level of its fellow, an elevation accompanied in most instances by 
rotation, so that its lower angle is brought nearer to the spine. The 
cervical muscles passing to the scapula are shortened and changed in 
direction. Thus its mobility is lessened and consequently the range 
of vertical extension of the arm is restricted. 
In many instances the deformity is accom- 
panied by a lateral curvature of the spine, 
the convexity being usually toward the de- 
formed side. In a case treated at the Hos- 
pital for Ruptured and Crippled, the eleva- 
tion of the scapula was accompanied by 
marked torticollis and asymmetry of the face, 
and in two cases recently reported by H. A. 
Wilson l the posterior border of the scapula 
was fixed to an elongated cervical spinous 
process. 

The first adequate account of the deformity 
was that of Sprengel, 2 who described four 
cases in children from one to seven years of 
age. In 1898 Pitsch 3 described seventeen 
other cases collected from literature, and since 
then a large number of cases have been re- 
ported by other observers. In four cases, 
three reported by Kolliker 4 and one by 
Hoffa, the projecting upper border of the 
scapula, reaching nearly to the clavicle, was 
mistaken for an exostosis. 

Etiology. — The etiology is doubtful, but 
the deformity appears to be the result of a 

constrained position of the foetus in utero. In two of Sprengel's cases 
seen soon after birth, the arm appeared to have been fixed behind the 
back of the child. 

Congenital elevation of the scapula may be simulated by the distor- 
tion and muscular atrophy resulting from birth palsy, or even by cer- 




Congenital elevation of the left 
scapula. (Wilson.) 



1 Annals of Surgerv, April, 1900. 

2 Archiv fur klin. Chir., Bd. 42, 1891. 



Zeit. fur Orth. Chir., Bd. 6, H. 1, 
Centb. fur Chir., 1895. 



186 DEFORMITIES OF THE CHEST 

tain cases of rotary lateral curvature in which the scapula is elevated 
and prominent. 

Treatment. — If the case is seen in infancy and if the contraction of 
the vertebro-scapula muscles is extreme, the shortened tissues may be 
divided by open incision as in torticollis, and if, as in Wilson's cases, 
the scapula is joined to the spine the elongated spinous process should 
be removed. In older subjects no treatment, other than that for the 
lateral curvature, is as a rule indicated. 

The Absence of Vertebrae. 

Absence of vertebrae is usually associated with rhachischisis. Three 
cases however have come under my observation in which there was 
absence of vertebras without other malformation. In two of the 
cases the deficiency was in the cervical region, in one in the lumbar. 
The noticeable shortness of the affected section of the spine was the 
only symptom. 

Deformities of the Chest. 

The Flat Chest. — The so-called flat chest is an accompaniment of 
the round back. (Fig. 136.) In most instances the chest is not ac- 
tually flattened in the sense that its antero-posterior diameter is dimin- 
ished. It appears flatter because the shoulders and scapulae are dis- 
placed forward. 

Woods Hutchinson has called attention to the fact that the so-called 
flat chest is usually a round chest, in the sense that it is actually 
deeper than the normal, a persistence of the foetal type. He suggests 
that such persistence may be one of the causes of so-called round shoul- 
ders, the round chest affording no adequate support for the scapulae. 

Hutchinson l has presented an index showing the relative depth of 
the chest at different ages, illustrating the progress from the keel chest 
of the lower orders to the bellows shape of the adult human form. 
This index is found by dividing the antero-posterior diameter at the 
nipples by the transverse diameter at the same level, hence the lower 
the index, the longer and flatter, more bellows-like the chest. 

Foetal index , 103 

Infantile " 87 

Child " 90 

Adult " 72 

Treatment. — The treatment of the so-called flat chest is similar to 
that of the round shoulders with which it is often combined, that is 
by exercises conducted with the special object of improving the 
strength of the muscles of the back and increasing the expansion of 
the upper part of the chest. The importance of correcting the de- 
formity, which interferes with the proper expansion of the lungs and 
thus predisposes to disease, should be evident. 

Pigeon Chest, Synonym. — Pectus Carinatum. 

1 Journal American Medical Association, Sept. 11, 1897. 



THE FUNNEL CHEST. 



187 



The pigeon, or keel-shaped, chest resembles the quadrupedal type 
in that the antero-posterior is increased at the expense of the lateral 
diameter. The sternum is thrust forward and downward like the keel 
of a boat, the lateral compression being most marked at the junction of 
the ribs and the cartilages. This deformity is almost always acquired 
(Fig. 142); it is usually an effect of rhachitis and it is described under 
that heading. It may be induced by obstruction of respiration caused 
by enlarged tonsils and the like, if this is present at an early age. It 
may be a secondary effect of the sinking forward and downward of the 

Fig. 142. 




General rhachitie distortions and pigeon chest. 



upper half of the trunk as in Pott's disease of the middle of the spine. 

Treatment. — The treatment would be included in the treatment of 
the affection of which it is the result. The tendency in rhachitie 
pigeon chest is toward spontaneous cure ; it is rarely seen in adult life. 

The Funnel Chest. Synonym. — Pectus Excavatum. 

This deformity when well marked is the direct opposite of the keel 
(Fig. 143) chest. The sternum is depressed and the lateral diameter of 
the thorax is correspondingly increased. The milder types of the af- 
fection in which there are one or more depressions or hollows in the 



188 



DEFORMITIES OF THE CHEST. 



Fig. 143. 



sternum are common. The extreme form, in which the entire sternum 
is depressed, is rare. It is practically always a congenital deformity, 
and it is not susceptible to direct treatment. 

Minor Deformities of the Chest. — As has been stated, distor- 
tions of the chest secondary to de- 
formity of the spine are often dis- 
covered before the original cause 
is suspected. And the importance 
of the various minor irregularities 
of the chest or in the direction of 
the ribs when once discovered is 
often exaggerated. They are usu- 
ally the result of preceding rhachi- 
tis and no especial treatment is re- 
quired. 

Absence of Ribs. — Absence or 
defective formation of ribs is un- 
common. In such cases there is 
usually defective formation of the 
corresponding muscles, and lateral 
curvature of the spine is a common 
accompaniment. 

Defective Formation of the 
Pectoral Muscles. — Several in- 
stances in which one or both of the 
pectoral muscles were defective or 
absent, have been observed at the 
Hospital for Ruptured and Crip- 
pled. The malformation in these 
cases caused no direct symptoms. 

Absence or Defect of the Clav- 
icle. — A number of cases of defec- 
tive formation of the clavicle on one 
or both sides are recorded. In most 
instances a portion of the sternal ex- 
tremity is present. The defect appears to cause but slight inconvenience. 1 




Pectus excavatum. This patient has ocular 
torticollis also. 



Acquired Luxation or Subluxation of the Clavicle. 

Partial displacement of the sternal end of the clavicle is not particu- 
larly uncommon. In some instances it is caused by injury ; in others 
no cause can be assigned. Most often there appears to be a laxity of 
the capsular ligament that allows a displacement during certain move- 
ments of the arm. The displacement is readily reduced, but the 
weakness and insecurity may cause discomfort and disability. 

Treatment. — In some instances the displacement may be prevented 
by the pressure of a pad and truss spring, attached behind to the corset 

1 Schornstein and Carpenter, Lancet, Jan. 7, 1899. 






ASYMMETRICAL BEVEL OPMEXT. 



189 



or braces and passing over the shoulder close to the neck. Such an 
appliance is especially useful if the displacement occurs at certain 
times only, as in dressing the hair, playing on the violin, etc. Cures 
are reported as the result of the injection of alcohol into the joint from 
time to time, and Wolff 1 has operated with success as follows : The 
joint is opened by a straight incision. A fragment of bone is detached 
from the clavicle above and a similar one from the sternum ; these, 
still adherent to the periosteum, are overlapped in front of the joint and 
the capsule is then sutured. 

Asymmetrical Development. 

In normal individuals there is often a slight difference between the 
two halves of the body and as is well known, inequality in the length 
of the legs is not at all uncommon. Inequality of the two halves of 

Fia. 144. 




Hypertrophy of the right forearm and hand, due to congenital nsevus. 

the body may be congenital and it may be evident at birth, but usually 
it does not attract attention until adolescence. In many instances this 
inequality is a slight atrophy, the result of a cerebral hemiplegia of early 
childhood. In other instances the inequality may be due to congenital 
hypertrophy that may affect the entire limb. In such cases the enlarge- 
ment, fur Chir., Nov. 30, 1893. 



190 



THE FUNCTIONAL PATHOGENESIS OF DEFORMITY. 



ment may be due to an abnormal amount of normal tissue, but in most 
instances the hypertrophy, which becomes more marked with the 
growth of the child, is caused by an abnormal blood supply, a form of 
congenital nsevus. (Fig. 144.) 



Tables of Weight, 



Height and Circumference of the Chest. — 
Boas. 







Pounds. 


Kilos. 


He 


ght. 


Chest. 




In. 


Cm. 


In. 


Cm. 


Birth 


f Male. 
\ Female. 


7.55 
7.16 


3.43 
3.26 


20.6 
20.5 


52.5 
52.2 


13.4 
13.0 


34.2 
33.2 


6 months 


f Male. 
\ Female. 


16.0 
15.5 


7.26 
7.03 


25.4 
25.0 


64.8 
64.6 


16.5 
16.1 


42.0 
41.0 


1 year 


f Male. 
\ Female. 


20.5 
19.8 


9.29 

8.84 


29.0 

28.7 


73.8 
73.2 


18.0 
17.4 


45.9 
44.4 


n Q ,, f Male. 
18 months { Female> 


22.8 
22.0 


10.35 
9.98 


30.0 
29.7 


76.3 

75.6 


18.5 
18.0 


47.1 
45.9 


2 years 


f Male. 
\ Female. 


26.5 
25.5 


12.02 
11.56 


32.5 
32.5 


82.8 
82.8 


19.0 
18.5 


48.4 
47.0 


3 years 


f Male. 
\ Female. 


31.2 
30.0 


14.14 
13.60 


35.0 
35.0 


89.1 
89.1 


20.1 
19.8 


51.1 
50.5 


4 years 


f Male. 
\ Female. 


35.0 
34.0 


15.87 
15.41 


38.0 
38.0 


96.7 
96.7 


20.7 
20.5 


52.8 
52.2 


5 years 


f Male. 
X Female. 


41.2 

39.8 


18.71 
18.06 


41.7 
41.4 


106.8 
105.3 


21.5 
21.0 


54.8 
53.5 


6 years 


f Male. 
\ Female. 


45.1 
43.8 


20.48 
19.87 


44.1 

43.6 


112.0 
110.9 


23.2 

22.8 


59.1 

58.3 


7 years 


f Male. 
X Female. 


49.5 
48.0 


22.44 

21.78 


46.2 
45.9 


117.4 
116.7 


23.7 
23.3 


60.6 
59.5 


8 years 


/ Male. 
\ Female. 


54.5 
52.9 


24.70 
24.01 


48.2 
48.0 


122.3 
122.1 


24.4 
23.8 


62.2 
60.8 


9 years 


f Male. 
X Female. 


60.0 
57.5 


26.58 
26.10 


50.1 
49.6 


127.2 
126.0 


25.1 
24.5 


63.9 
62.5 


10 years 


j Male. 
\ Female. 


66.6 
64.1 


30.22 
29.07 


52.2 
51.8 


132.6 
131.5 


25.8 
' 24.7 


65.6 
63.0 


11 years 


J Male. 
\ Female. 


72.4 

70.3 


32.83 
31.87 


54.0 
53.8 


137.2 
136.6 


26.4 

25.8 


67.2 
65.8 


12 years 


f Male. 
X Female. 


79.8 
81.4 


36.21 
36.90 


55.8 
57.1 


141.7 
145.2 


27.0 
26.8 


68.8 
68.3 


13 years 


f Male. 
X Female. 


88.3 
91.2 


40.04 
41.36 


58.2. 
58.7 


147.7 
149.2 


27.7 
28.0 


70.6 
71.3 


14 years 


f Male. 
X Female. 


99.3 
100.3 


45.03 
45.50 


61.0 
60.3 


155.1 
153.2 


28.8 
29.2 


73.3 
74.1 


15 years 


f Male. 
X Female. 


110.08 
108.04 


50.26 
49.17 


63.0 
61.4 


159.9 
155.9 


30.0 
30.3 


"* 76.6 
76.8 



THE FUNCTIONAL PATHOGENESIS OF DEFORMITY. 
Wollf'sLaw. 

Mention has been made, and will be made again from time to time, 
of the adaptation of members or parts to abnormal conditions, and of the 
transformation of deformed parts to the normal when the improper re- 



WOLLF'S LAW. 191 

lations of weight and strain have been removed. This theory or law of 
functional adaptation has been established by Professor Julius Wollf, of 
Berlin, who has shown its application to the bones, the most unyield- 
ing structures of the body. He first called attention to the fact that 
the shape of a bone is the effect of function. It is the effect of func- 
tion in that if the work required of it had been different, its shape 
would have been different. This function has shaped not only the 
external contour but the internal structure as well. If a bone is 
broken, for example the neck of the femur, and deformity results, the 
internal architecture is no longer suitable for the new conditions of 
weight and strain, and immediately a rearrangement begins, which 
finally transforms the internal structure, not only in the neighbor- 
hood of the injury, but in the extremity of the bone also, to adapt 
the deformed part as well as may be to the work that is now de- 
manded of it. 

The normal bone is braced most thoroughly, and is most resistant 
at the points where most work is required of it. If the weight and 
strain are for any reason transferred to another part, its structure be- 
comes hypertrophied there, and correspondingly weakened at the point 
from which the strain has been removed. With this change in the in- 
ternal structure a change in the external contour keeps pace. 

For the further exposition of this theory I quote from Freiberg's l 
review and abstract of Wollf s 2 final article. 

" In showing that improper static demands made upon an extremity 
resulted in the formation of new masses of bone upon the surface of 
the bone of this extremity, or that they produced the disappearance 
(atrophy) of bone masses according to the nature and degree of these 
disturbances in static requirements, it has at once been shown in what 
manner deformities have their origin. For these transformations on 
the surface of bones are nothing other than ' deformities ? in the wider 
or narrower sense of the term. 

" Taking genu valgum or habitual scoliosis as example, the develop- 
ment of a deformity in the narrow sense is thus explained. In the 
beginning of either of these conditions the shape of the bones is per- 
fectly normal. As the result of excessive fatigue in their too weak 
muscles the patients are frequently assuming a faulty position of limb 
or body ; they seek to control excessive excursions of their joints by 
the interference of the articular structures themselves, instead of by 
muscular activity. The result is a continual alteration in the static 
requirements made upon the bones and the internal architecture ; in- 
ternal and external configuration of the bones accommodate themselves 
to the new conditions. Since, according to this reasoning, deformities 
are nothing else than the result of these transformations which the ex- 
ternal form of bones or joints undergo in accommodating itself to 
faulty demands made upon them, it must be self-evident that these de- 

1 Annals of Surgery, July, 1897. 

2 Jul. Wollf, Die Lehre von der functionellen Pathogenese der Deformitaten 
Archiv fur klinische Chirurgie, Bd. LIIL, H. 4. 



192 THE FUNCTIONAL PATHOGENESIS OF DEFORMITY. 

formities are to be considered pathological only in the sense that hy- 
pertrophy of the cardiac muscle in valvular insufficiency is pathological. 
That which is really pathological is only the altered static require- 
ments, the abnormal mechanical function. Far from being pathological 
the deformity is the only suitable or even possible form by means of 
which bone or joint can withstand the altered forces bearing upon it ; 
it is nature's way of securing the greatest possible service and strength, 
under the new conditions, with the use of the least possible amount of 
material, jj 

" The pathogenesis of deformities is therefore functional. Genu val- 
gum, for instance, represents only the functional accommodation of 
femur, tibia, and knee-joint to the improper static demands made by 
the outward deviation of the leg. Just so are the shapes of the bones 
in club-foot the expressions of similar functional accommodation to an 
inward rotation of the foot, or even, sometimes, an inward turning of 
the whole lower extremity. The faulty position of an extremity under 
these circumstances is to be regarded rather as a cause of the deformity 
than as an effect. This faulty position must always occupy a place 
intermediate between the remote causes of deformity (hereditary pre- 
disposition, habit, muscular weakness, external conditions causing 
pressure or narrowing space for growth) and the anatomical results 
which these various remote causes bring about. 

" When the altered demands upon an extremity do not occur spon- 
taneously, as in the above instances, but, on the other hand, result from 
a primary disturbance in the shape of the bones, due to trauma or 
bone-disease with consequent softening or destruction of tissue, there 
is added to this a secondary change in the external configuration of the 
bones, and there is thus caused a ' deformity in the broad sense of the 
word/ The difference between the two varieties of deformity, there- 
fore, lies only in the addition of a second etiological factor (the trauma, 
etc.) to the deformity in the broad sense. Both varieties have it in 
common that the shape of the bones and joints of the deformed part 
represents nothing else than the expression of a functional accommoda- 
tion to the faulty static demands made upon it." 

" As a second example by means of which to explain the correctness 
of the doctrine of functional pathogenesis the author has selected 
scoliosis. In the first chapter the author showed in detail that the 
altered conditions in the length and height of the transverse processes 
of scoliotic vertebrae as well as corresponding conditions in the ribs of 
the scoliotic thorax are so evident as not possibly to escape notice, and 
that they can be explained in no other way than as functional accom- 
modation to the circumstances of space, changed and brought about by 
the continual, faulty, and cramped position of the thorax ; this is as 
true of the convex as of the concave side of the vertebral column, to 
which the transverse processes and ribs in question belong. It must 
be manifest that changed relations of one part of the skeleton to any 
other part of the skeleton (as far as space conditions are concerned) 
necessarily bring about changes in the mechanical demands made upon 



WOLLF'S LAW. 193 

this part, and therefore changes in the directions and values of the 
pressure, tension, and shearing strains of each and every point in this 
part of the skeleton. The conclusion thus drawn, that accommodation 
to space means the same as accommodation to function, is of greatest 
importance to the general doctrine of functional accommodation. 

" The origin of the wedge-shape of the scoliotic vertebra now comes 
under discussion. It is assumed by the majority of writers that an 
abnormal softness of the bones is present in scoliosis by means of 
which a faulty position can model the bodies of the vertebrae as it does 
in the case of rachitic disease of bone, or as is really the case with the 
intervertebral discs in cases of ' habitual scoliosis.' While unsup- 
ported by any pathologic-anatomical investigations, it is allowed pos- 
sible, or even probable, that such softness of the bones plays a role in 
many cases of scoliosis. It is certain, however, that this is by no means 
always the case ; as evidenced by the development of scoliosis after 
empyema in adults, and the great exaggeration in adult life of very 
slight scolioses originating during youth. It is concluded, on the con- 
trary, that the vertebra may acquire its scoliotic wedge shape entirely 
independent of the pressure of the superincumbent weight. Further- 
more, in the absence of any abnormal softness of the bones, the body 
of a vertebra may lose height on the concave side, and gain the same 
on the convex side through the ' tropic stimulus of function ' purely ; 
being simply an accommodation to the diminished space on the concave 
side and increased room at the convexity and the change of mechanical 
conditions consequent thereupon. 

" This simple and natural conception of the circumstances concern- 
ing the scoliotic wedge must obtain credence, especially since the old 
view, corresponding to the ' pressure theory/ has been long ago dis- 
proved by Hoffa and Nicoladoni — namely, that the concave side of the 
wedge is the seat of atrophy, and that this atrophy accounts for the 
loss in height of the vertebral body on this side." 

The importance of Wollf s theory which shows how deformity may be 
acquired and how it may be avoided, is very evident. It is of equal 
importance in indicating the principles of treatment. For example, 
from the anatomical description of a club foot the distortion might 
appear to be irremediable, but on this theory one feels assured that 
if the foot can be fixed for a sufficient time in the over-corrected posi- 
tion, the influence of the new static conditions will immediately induce 
a transformation, not only in soft parts but in the bones as well, that 
will finally effect a complete and absolute cure. So also the correction 
of a distorted bone by operative means is at best but imperfect ; if 
however the static conditions have been changed, nature will in time 
reconstruct the entire bone so perfectly that, in a few years, practically 
no trace of the former distortion, either in contour or internal struc- 
ture, will be evident. Scoliosis might be cured as perfectly as the club 
foot or the bow leg, were it possible to restore as easily the normal 
conditions of weight and strain. 
13 



CHAPTER V. 

TUBERCULOUS DISEASE OF THE BONES 
AND JOINTS. 

Etiology. — Three factors are recognized in the etiology of tubercu- 
lous disease : the infectious element (the tubercle bacillus), the general 
predisposition of the patient, and the local condition that favors the 
reception and the growth of the bacilli. 

Predisposition. — The predisposition, both general and local, is 
spoken of as lessened vital resistance. A general predisposition to dis- 
ease may be inherited, or it may be acquired. Thus a history of tuber- 
culosis in the immediate family of the patient is supposed to imply a 
lessened resistance to this form of disease. In a certain proportion, 
perhaps 25 per cent, of the cases, this inherited predisposition is very 
direct and positive, but in the larger number the family history is as 
indefinite as in a similar class of patients under treatment for any other 
form of ailment. The acquired predisposition is of more direct impor- 
tance since it would include the lowering of the vitality due to improper 
food and improper hygienic surroundings of every variety, together 
with the greater liability to depressing diseases and the more constant 
exposure to tuberculous infection that such conditions imply. Thus 
tuberculous disease of the bones, as well as of other parts, is more com- 
mon among the poor of cities than among the more favored classes. 

Mode of Infection. — The tubercle bacilli may be introduced to 
the body by inhalation and find their way to the bronchial glands, or 
by the mouth and set up disease in the mesenteric glands, or, after in- 
fection of the nasal passage or neighboring parts, secondary disease of 
the cervical lymphatics may appear in the so-called scrofulous glands 
of the neck. 

Latent Tuberculosis. — It may be assumed that disease of the 
bronchial and mesenteric glands is not uncommon in individuals of 
apparently perfect health since it is often discovered at autopsies in 
those who have died from other causes. This form of glandular dis- 
ease is called latent tuberculosis and it usually precedes a local outbreak 
in the bone or elsewhere. In many instances the disease may remain 
latent and finally disappear or it may persist and from time to time free 
bacilli or bits of infected tissue may escape into the blood current ; by 
it they are deposited in other parts, where, under favoring conditions, 
local disease may be set up. Depression of the vitality from any cause 
may be supposed to favor the progress of the glandular disease which 
may lead to a dissemination of the infectious elements, and at the same 
time it may lessen the resistance of other tissues that may be exposed 



ETIOLOGY. 195 

to the infection. This accounts for the well-known influence of certain 
diseases such as measles and whooping-cough, not only in predisposing 
to local tuberculous disease, but in favoring its progress when it is 
already established. It is, however, possible that the bacilli that have 
found their way into the blood current, may set up primary disease of 
a bone or joint. In fact it is stated by Konig 1 that in 14 of 67 autop- 
sies on subjects who had suffered from tuberculous disease of the bones 
and joints, no other foci were found in the body. And in other in- 
stances the source of infection may be preexistent disease of the lungs 
or of other internal organs. 

In 769 autopsies on children under twelve years of age, at the 
Hospital for Children, Great Ormond St., London, reported by G. F. 
Still, 2 269 presented tuberculous lesions. Of these 269, 117 were less 
than two years of age. 

The apparent channels of infection, as evidenced by the appearance 
of the glandular lesions, were as follows : 

Respiratory. 

LuDgs 105 

Probably lungs 33 

Ear 9 

Probably ear 6 

153 — 57 per cent. 

Alimentary. 

Intestines 53 

Probably intestines 10 

63—23.4 per cent. 

Other Cases. 

Bones or joints 5 

Fauces 2 

Uncertain 46 

53^ 

Northrup and Bovaird 3 have made similar observations at the N. Y. 
Foundling Hospital. 

Infection by respiratory tract 148 

Infection by mesenteric lymph nodes 3 

Indeterminate 48 

200 

In sixteen instances the process was confined to the bronchial glands 
and in no instance were these glands found to be free from disease. 

Local Predisposition. — The local conditions that favor the growth 
of the tubercle bacilli may be induced by injury. Slight injury suffi- 
cient to cause, for example, a hemorrhage into the substance of the 

1 Deutsch Chir., L. 28a, S. 157, 1900. 
2 British Med. Jour., August 19, 1899. 

3 Northrup, N. Y. Med. Jour., February 21, 1891. Bovaird, N. Y. Med. Jour., 
July 1, 1899. 



196 TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 

cancellous tissue, induces a local congestion during the process of repair 
that provides the proper soil for the growth of the bacilli when they are 
deposited in its neighborhood. This has been proved experimentally 
by Krause and it is supported by clinical evidence. The great prepon- 
derance of disease in the lower over that of the upper extremities in 
childhood is supposed to be another argument in favor of the influence 
of injury in the causation of disease. 

In 271 of 1,156 cases of tuberculosis of the bones and joints, treated 
at the Clinics at Gottingen and Breslau, 1 injury seemed to be a di- 
rect predisposing cause of the local disease, twenty-three per cent. A 
much higher percentage than this has been assigned by other writers, 
but the exact relation of traumatism to disease can only be conjectured. 

The seat of the disease is almost always in the newly formed bone 
about an epiphyseal cartilage. This tissue is vulnerable ; it is there- 
fore more exposed to direct injury; it is subjected also to the strain 
of motion at the neighboring joint, and as the circulation is here more 
active the bacilli are more often deposited in this situation. 

The vulnerability of growing bone accounts also for the relative fre- 
quency of bone disease in childhood, as compared with adult life. In- 
jury not only causes a local predisposition to disease, but it favors its 
progress when it is once established. 

Distribution of the Disease. — In 13,308 cases of tuberculous disease 
of the bones and joints treated at the Hospital for Ruptured and Crip- 
pled the distribution was, in order of frequency, as follows : 

Vertebrae 5, 662 42. 5 per cent. 

Hip Joint 4,048 30.5 " 

Other Joints 3,598 27.0 " 



In a total of 3,561 cases treated at the Hospital for Ruptured and 
Crippled and at the Vanderbilt Clinic, during the past five years, the 
distribution was as follows : 



Vertebrce 1,432 40.2 per cent. 

Hip Joint 1,123 31.5 " 

Knee " 699 19.6 " 

Ankle " 196 5.5 " 

Elbow " 62) 

Shoulder" 42 V 3.1 " 

Wrist " 7) 

3,561 

Trunk 1,432 40.2 per cent. 

Lower Extremities 2,018 56.6 " 

Upper " Ill 3.1 " 

The correspondence between these two tables of statistics is striking 
and the number of cases is so large that the proportions may be ac- 
cepted as approximately correct as applied to the distribution of the 
disease in childhood. 

1 Krause, Deutsch Chir., L. 28a, S. 161, 1900. 



ETIOLOGY. 197 

At the Boston Children's Hospital in a period of twenty-five years, 
1869-1893, 3,820 cases were treated. 1 The distribution was as follows : 

Vertebrae 1 ,964 51.4 per cent. 

Hip 1,402 36.7 " 

Ankle 300 7.8 

Knee 104 2.7 " 

Wrist 20) 

Shoulder 15 I 1.3 " 

Elbow 15 J 

3,820 

Trunk 1,964 51.4 per cent. 

Lower Extremities 1,806 47.2 " 

Upper " 50 1.3 " 

Side Affected. — Disease of the joints is slightly more common on 
the right than on the left side of the body. At the Hospital for Rup- 
tured and Crippled the proportions in the cases treated during the past 
ten years, are as follows : 

Hip — right 53 per cent. 

Knee — right 55 " 

Ankle— right 50 " 

Shoulder— right 64 " 

Elbow— right 60 " 

It has been stated that one of the explanations of the great prepon- 
derance of the disease of the lower over the upper extremity, is the 
greater liability to injury . The same explanation has been advanced 
to account for the greater frequency of disease on the right side, which 
is more marked in the upper than in the lower extremity because the 
right arm is more liable to overwork as well as to injury. 

Sex. — Tuberculous disease of the joints is somewhat more common 
among males than females. 

Of 3,822 cases of Pott's disease treated at the Hospital for Rup- 
tured and Crippled, 2,037 or 53 per cent, were in males. 

Of 3,307 cases of disease of the hip joint treated at the same insti- 
tution 1,731 or 52.3 per cent, were in males. 

Of 1,218 cases of disease of the knee joint, combined statistics of 
Koenig and Gibney, 703 or 57.6 per cent, were in males. 

Age. — In 5,461 cases of tuberculous disease treated at the Hospital 
for Ruptured and Crippled, about seven-eighths of the patients were 
less than fourteen years of age. 

f Vertebrae 87.7 per cent. 

Less than 14 years of age I Hip 88.2 

I Other joints.. 71. 7 



Between 14 and 21 years of (Vertebrae H pei 

° ( Other joints.. 10. 7 



( Vertebrae 4.5 per 

More than 21 years of age 1 Hip 2.5 

I Other joints.. 17.5 ; 
1 Report of the Boston Children's Hospital. 2 Knight, Orthopedia: 



cent. 



cent. 



198 TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 

Of 1,259 cases of Pott's disease treated recently at the same insti- 
tution, 1,075, 85 per cent, of the patients were in the first decade ; 50 
per cent, were three to five years of age inclusive at the inception of 
the disease. 

In 1,000 cases of disease of the hip joint, the ages of the patients 
correspond closely to these, 87.2 per cent, were in the first decade and 
45.2 per cent, were from three to five years of age inclusive. 

In 1,000 cases of disease of the knee joint, 75 per cent, were in the 
first decade and 40 per cent, were from three to five years inclusive. 

In 339 cases of disease of the ankle joint, 70 per cent, were in the 
first decade and but 35 per cent, were included within the three years. 

The distribution of the disease and its relative frequency at the dif- 
ferent ages is shown by Alfer's table of statistics from Trendelenburg's 
clinic at Bonn. 1 





0-5 


5-10 


10-15 


15-20 


20-25 


25-30 


30-35 


35-40 


40-45 


45-50 


50-55 


55-60 


60-65 


65-70 


Total. 


Vertebrae 

Hip 


89 
58 
47 
5 

7 
1 


59 

59 

52 

9 

2 

14 




32 

43 
47 
10 

2 
14 




23 

46 

37 

5 

6 

21 

1 


9 

9 
20 

2 

3 
12 

5 


10 
11 
11 

1 

5 
9 



3 

6 

23 

1 
3 
6 



6 



11 

3 
1 
5 
3 


3 

4 

11 

2 
1 
9 
1 


1 
1 

3 


2 
8 
3 


4 
1 

2 
3 
2 
5 

2 




3 

8 

1 
2 

1 





6 
2 

2 
3 




3 






239 
241 




281 


Ankle 


43 


Shoulder 

Elbow 


28 
114 


Wrist 


20 






Total 


207 


195 


148 


159 


60 


47 


42 


29 


31 


18 


19 


15 


13 


3 


966 



This table illustrates the well-known fact that disease of the upper 
extremity, relatively infrequent at all ages, is proportionately far more 
common in adult life than is disease of the lower extremity. Of the 
joints of the lower extremity, the knee and the ankle are proportion- 
ately more often diseased in later life than is the hip. 

Pathology. — When the bacilli are deposited in a part, the irritation 
of their toxines causes a proliferation of the fixed cells which lie in 
direct contact with the germs, and about these a ring of leucocytes 
forms. The bacilli, the epithelioid cells including often one or more 
giant cells, together with the surrounding leucocytes, constitute the vis- 
ible tubercle of bone, a minute grayish speck in the cancellous structure. 
The central cells about the bacilli, increasing in number, deprived of 
nourishment and poisoned by the toxines, die and are disintegrated 
to granular material, " caseate," and the tubercle changes to a yellow 
color ; but the bacilli, multiplying and escaping, form new tubercles 
about the original focus, which coalesce as the area of the disease en- 
larges. Meanwhile the surrounding tissue becomes congested, as the 
result of the irritation, and the fixed cells become organized, or partly 
organized, into a feeble, ill-nourished form of granulation tissue, rep- 
resenting the effort of the part to shut out and to expel the foreign sub- 
stances formed by the disease. Or, if this local resistance is effective, 
the cells become actually organized into firm granulations which sur- 
round and destroy the germs, and then are further transformed into 
'Beit, ziirklin. Chir., 1891, Bd. 8. H. 2. 



PATHOLOGY. 199 

scar tissue. Bat in most instances either because the irritation is in- 
sufficient or because of the deficient vitality of the part, the granula- 
tions are feeble and unstable and they in turn become infected and de- 
stroyed by the multiplying bacilli, thus serving only to extend the 
area of the disease. This granulation tissue, before and after the 
stage of infection, absorbs and destroys the bone. If the progress of 
the disease is slow, the cancellous structure is completely absorbed or 
is represented only by bone sand, but if the disease infiltrates the bone 
more rapidly it may destroy its vitality while its structure is still re- 
tained, and a sequestrum is formed. Such sequestra, consisting of 
rounded, yellow, crumbling masses of cancellous structure, from the 
size of a pea to a hazel nut, are especially common in epiphyseal dis- 
ease of childhood. In rare instances, wedge-shaped sequestra are 
found with the base at the periphery of the epiphysis. These are sup- 
posed to be caused by the lodging of an infected embolus in a terminal 
vessel, which causes the immediate death of the part by cutting off its 
blood supply. 

By the formation of new tubercles at the periphery, and by the 
caseation of material in the center of the diseased area, a cavity in 
the bone is formed, containing the debris of the granulation tissue and 
often sequestra of larger or smaller size, and a variable amount of fluid, 
made up of serum and leucocytes, that has exuded from the surround- 
ing granulations. The walls of this cavity are formed by the tissue 
in which the disease is active ; the inner layer containing the tubercles 
in the various stages of formation and decay, the outer, composed of 
feeble, ill-nourished, granulation tissue as yet not infected, and beyond 
this the softened and infiltrated bone. If the disease has ceased to 
progress in any direction, the granulations contain more blood ves- 
sels, they are of firmer consistency and more perfectly organized, and 
the substance of the bone is harder, showing the evidence of repair. 

One termination of epiphyseal disease is by enclosure of the focus by 
resistant granulations, behind which the bone solidifies and .shuts in 
the disease or in favorable cases in which its area is small, completely 
absorbing and replacing it by scar tissue. 

Extra- articular Disease. — As a rule, the tendency of the proc- 
ess is to expand and to force an opening through the cortex of the bone 
to the exterior. In certain cases this opening may form outside the 
capsule of the joint, and through it the products of the disease may be 
discharged into the overlying tissues forming a tuberculous ab- 
scess. Here, the same process of infection and extension of the area 
of disease continues, but more rapidly than when it was confined Avithin 
the bone ; the surfaces of the muscles and fascia are infected and are 
covered with an abscess membrane of violet or grayish yellow color, 
made up of tubercular tissue and masses of fibrin, lying upon, and 
loosely attached to, the outer inflammatory or healthy granulations. 

The cavity of the abscess is distended with tuberculous pus usually 
of a thin consistency, composed of serous exudation, leucocytes, fibrin, 
masses of degenerated tissue and fragments of bone or bone sand. It is 



200 TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 

commonly of a whitish color, occasionally reddish from mixture with 
blood, and in the later stages, yellow and serous-like. The abscess en- 
larges in the direction of least resistance, and in most instances finally 
perforates the skin by one or more openings through which its con- 
tents are discharged. Or, its boundaries may cease to extend, its con- 
tents may be absorbed, adhesions may form between its walls, and a 
spontaneous cure is effected. This course, in which the disease remains 
extra-articular, is unusual. It is more common at those joints like 
the knee, elbow and ankle, in which the bones are superficial ; it is 
very uncommon at the hip joint and it is practically impossible in dis- 
ease of the spine. 

Perforation of the Joint. — Usually the tuberculous process 
within the epiphysis, enlarging its area, comes into contact with car- 
tilage, and perforating this finds its way into the joint. While the 
disease is still confined within the bone, the tissues within the joint are 
involved in a sympathetic irritation or inflammation. The synovial 
membrane becomes congested and hypertrophied, the synovial fluid is 
increased and changed in quality, fibrin forms and is deposited upon 
the cartilage and upon the lining membrane of the capsule. It is 
stated by Koenig that the organization of these fibrinous deposits upon 
the cartilage plays an important part in its destruction, even when 
actual tuberculous disease is absent. As a result of the sympathetic 
inflammation within the joint, adhesions may form which may limit the 
area of the tuberculous disease and retard its progress, after perfora- 
tion has taken place. This process is similar to the inflammatory 
changes in the pleura caused by the underlying tuberculous disease. 

When the disease comes into contact with the cartilage, it disinte- 
grates ; the tuberculous granulations breaking through and spreading 
over its surface destroy it in piecemeal, or advancing beneath it, 
separate it from the bone in large, necrotic fragments. The synovial 
membrane becomes thickened and infiltrated, numerous tubercles ap- 
pear upon its surface, which undergo the secondary changes that have 
been described, and the joint becomes, practically speaking, an abscess 
cavity. The surfaces of the bones are disintegrated by the disease 
and the destruction is hastened by the pressure and friction due to 
muscular spasm and to functional use. The thickened capsule, distended 
by the fluid and solid products of the disease, is usually perforated, 
and a secondary abscess, communicating with it, is formed in the sur- 
rounding tissues. As results of the disease, secondary changes ap- 
pear in the neighboring parts. The irritation of the periosteum may in- 
duce the formation of irregular layers of bone or osteophytes about the 
joint. A new formation of connective tissue proceeding from the 
layer of granulations that surround the disease may extend to the 
muscles and tendon sheaths, binding them together, and causing limi- 
tation of motion. The newly-formed connective tissue may be very vas- 
cular and irregular in formation, and intermixed with it may be masses 
of gelatinous or myxomatous tissue. This, according to Krause, is due to 
the venous stasis and oedematous infiltration caused by the pressure of 



PATHOLOGY.. 201 

the capsular contents and extra-capsular proliferation of granulation tis- 
sue. These changes in the appearance and in the consistency of the tis- 
sues about the joint are characteristic of the so-called white swelling. 

Other Forms of Tuberculous Disease of Joints. — All of the German 
writers describe forms of primary synovial disease, its frequency varying 
from 16 to 35 per cent, of the cases. It is more common in adult life 
than in childhood and at the knee than at other joints. But Nichols x 
states that he has examined 120 tuberculous joints, and has found in 
every instance one or more foci in the bone that apparently preceded 
the disease in the joint. 

From the clinical standpoint, however, one must recognize a form of 
disease in which the symptoms differ from the ordinary osteal type. 
It begins as a chronic synovitis, although the tissues are more thickened 
and infiltrated than in simple synovitis, and the muscular atrophy is 
more marked. Reflex spasm and limitation of motion are slight and 
the symptoms are rather discomfort and fatigue after exertion than ac- 
tual pain. After many months, when it may be assumed the bones are 
involved, the characteristic symptoms of tuberculous disease appear. 
In one form the amount of effused fluid is large, and is clear and serous- 
like in character — hydrops tuberculosa ; but usually it is cloudy, and 
it may be purulent in character. 

As has been stated, Koenig lays stress upon the important part 
played by fibrin in the changes that take place within a joint. Fibrin 
deposited from the effused fluid forms in successive layers upon the 
cartilage. Into this fibrin, vessels grow from the hypertrophied and 
infected synovial membrane, destroying the cartilage together with the 
underlying bone. If the synovial disease is primary, the bone is de- 
stroyed from without, but if it is secondary to epiphyseal disease it is 
destroyed from within also. 

Arborescent Synovial Tuberculosis. — In this form the interior of the 
joint is covered with villous proliferations from the synovial membrane. 
These are formed, it is supposed, by the growth of blood vessels from the 
membrane into the layers of fibrin that are deposited upon its surface. 

Lipoma — Arborescens Tuberculosum. — Arborescent villous prolifera- 
tions may be formed of adipose tissue covered with synovial membrane 
which project into the joint. 

Rice Bodies. — Rice bodies are numerous small grayish-white bodies 
resembling cucumber seeds, that are found in certain forms of synovial 
disease and particularly in tuberculosis of tendon sheaths. They are 
formed of fragments detached from the proliferating synovial membrane 
and possibly of simple fibrin, which, under the influence of pressure 
and attrition in the movements of the joint or of the tendon, assume 
the characteristic shape and appearance. These bodies within a tendon 
sheath or joiut, cause a peculiar creaking, perceptible to the touch 
when the part is moved. 

Dry Caries — Caries Sicca. — In this form of disease, which is said to 
be primarily synovial, there is but little formation of fluid and there is 
1 Trans. Am. Orth. Ass'n, Vol. XL 



202 TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 

but little tendency toward cheesy degeneration of the tuberculous prod- 
ucts. The infected granulations destroy the bone without forming 
sequestra, and usually without suppuration. This form more often oc- 
curs at the shoulder joint, and it is characterized by marked limitation 
of motion, extreme atrophy of the surrounding parts, and sometimes 
by forward displacement of the partly destroyed head of the humerus, 
that may be mistaken for dislocation. 

Septic Infection. — When a tuberculous abscess has opened sponta- 
neously, or when it has been incised, infection with pyogenic germs is 
common and it occasionally occurs before a communication with the 
exterior has been established. After such infection the surrounding 
tissues become infiltrated, reddened, hot and sensitive to pressure. The 
discharge is greatly increased in quantity and changed in quality. The 
local pain and discomfort are aggravated and the constitutional effects 
of pyogenic infection appear. If the area of the abscess is small and 
if the drainage is efficient, this accident is of slight importance and it 
may even exercise a beneficial effect in stimulating the circulation and 
dissolving the effused material about a joint. But if the abscess has 
burrowed widely into surrounding tissues and if it communicates with 
an important joint, it is a dangerous complication, in fact the greatest 
direct danger of tuberculous joint disease. The persistent suppuration 
exhausts the patient and induces amyloid degeneration of the internal 
organs ; and by lessening the vital resistance it favors the local advance 
of the tuberculous disease and its general dissemination. 

Repair. — Repair in tuberculous disease may be accomplished by the 
absorption, ejection or enclosure of the disease. The process of repair 
usually accompanies the advance of the destructive process and ex- 
amples of the three methods of cure may be found in a single joint. 

The curative agent is the granulation tissue which forms about the 
area of disease and which finally becoming sufficiently organized to resist 
the infection of the bacilli, solidifies into fibrous tissue. In those cases 
in which the disease is not absorbed, or completely thrown off in the 
abscess formation, but is enclosed, it becomes quiescent. In such cases, 
under the influence of traumatism, when for example the surrounding 
adhesions are broken down in the attempt to rectify deformity or to 
overcome anchylosis, local recurrence of the disease may follow. 

Prognosis. — The prognosis will be considered more particularly in 
the sections on disease of special parts. The danger to life is direct and 
indirect, and this varies greatly with the part that is affected and with 
the age of the patient. 

In disease of the spine the direct danger to life is greatest, because 
of its situation since it may involve the spinal cord or extend to the 
important organs in the neighborhood. Abscess may in rare instances, 
merely by its size and situation, endanger life and when infected it is 
far more dangerous because of the difficulty in providing efficient 
drainage. The influence of deformity and its effect in compressing 
the internal organs and thus interfering with the vital functions is 
another more remote element of danger in disease in this situation. 



PROGNOSIS. 203 

The danger to life from disease of the joints is in proportion to their 
importance. In rare instances it may extend to the shaft of the bones 
and set up an extensive osteomyelitis ; or the patient may be weak- 
ened by the suffering caused by active disease, but, as has been 
stated, the most direct and constant danger is from prolonged suppu- 
ration that follows septic infection. Danger from this source is much 
greater at the hip joint than at the ankle or elbow, for example, be- 
cause of the greater difficulty in preventing the burrowing of pus 
when infection has occurred. 

The indirect danger of tuberculous disease is its dissemination to 
more important organs. But it by no means follows that the disease 
of the joint is the source of the general infection. 

For as has been stated, it may be inferred that nearly every patient 
with joint disease has also disease of the lymphatic glands, and in 
a small proportion of the cases there may be also active disease of 
important organs. Tuberculosis of the lungs, for example, is often 
present in the adult before the local outbreak in the joint appears, and 
it is in great degree because of this liability to disease of the lungs 
that the prognosis of joint disease becomes progressively worse with 
the age of the patient. 

This point is illustrated by the statistics of Koenig and Bruns on 
the final results of disease of the knee and hip joints, to which atten- 
tion will be called again in the special sections. In Koenig's cases of 
disease of the knee joint the death rate was in patients : 

Less than 15 years of age 20 per cent. 

From 16 to 30 years 24 " 

" 31 to 40 " 44 " 

More than 40 " 60 " 

In Brim's statistics, the death rate was of patients in the first decade 36 
per cent. — in the second decade 44 per cent. — older than this 72 per cent. 

The cure of latent tuberculosis in the lymph nodes as well as of 
active disease of the lungs or bones depends upon the vital resistance 
of the patient. This vital resistance is lessened by pain, by confinement 
and lack of exercise. It is directly impaired by the exhausting suppu- 
ration and by the poisoning of the toxines incidental to septic infec- 
tion. Under these conditions the local disease advances and a general 
dissemination is more probable. This accounts for the fact that death 
from general tuberculous infection is much more common in this class 
than when suppuration has been slight or absent. This point is again 
illustrated by the statistics referred to. The death rate in the cases of 
disease at the knee without abscess was twenty-five per cent., with ab- 
scess forty-six per cent. Death rate in cases of disease at the hip with 
abscess fifty-two per cent., without abscess twenty-three per cent. 

It is probable that tuberculosis may be disseminated by operation 
upon tuberculous joints, although the evidence upon this point is 
vague and conflicting. Gibney, contrasting two equal periods of thir- 
teen years of service at the Hospital for Kuptured and Crippled, in the 
first of which no operations were performed on tuberculous subjects, 



204 TUBERCULOUS DISEASE OF THE BONES AND JOINTS. . 

states that in his opinion the deaths from this source have been pro- 
portionately no greater during the period of active surgical interven- 
tion than before. And an investigation of the causes of deaths among 
the patients treated at the N. Y. Orthopaedic Dispensary and Hospi- 
tal during a period of twenty years, . showed that at least twenty-five 
per cent, of these were due to tuberculous meningitis. 1 During this 
period there had been, practically speaking, no operative intervention, 
yet the proportion of deaths from this cause is certainly as great as in 
any statistics that have been reported. It would appear then that the 
danger of dissemination is not sufficient to deter one from performing 
any operation that seems to be indicated by the local disease or by the 
general condition of the patient. 

Treatment. — From what has been stated of the causes of disease it 
follows that the general treatment should include, if possible, a change 
in the hygienic conditions, relief from the danger of further infection, 
pure air and proper food. These are as essential in the treatment of 
tuberculosis of the bones as of other parts. 

As far as the cure of local disease is concerned, no treatment can be 
as effective as the prompt and thorough removal of the focus of dis- 
ease, while it is yet limited in extent, and before the joint has become 
involved. This is practicable, however, in but a small proportion of 
the cases because it is usually impossible to locate the disease accu- 
rately and impossible to remove it without sacrificing much of the 
healthy bone upon which the future usefulness of the part depends. 
At one time early operation, even complete excision of the joint, was 
justified on the plea that the disease might thus be eradicated. But 
now that it is known that in nearly all cases other tuberculous foci 
exist in the body, and as the functional results after these early opera- 
tions are far inferior to those attained under conservative treatment, 
early excisions are limited to the adolescent or adult cases. For in 
this class growth has been attained and the economic conditions require 
that the period of disability should be as short as possible. Local 
treatment is therefore conducted with the aim of relieving the part of 
function, that is to say from strain and injury. Functional use of a 
diseased joint delays natural repair, since it causes pain and thus re- 
duces the natural forces, while it stimulates the disease and increases 
its destructive action. The details of treatment will be described in 
the consideration of disease of special joints. 

Treatment by Drugs. — The administration of drugs occupies a very 
subordinate place in treatment, since it is not believed that any drug 
exercises a direct action upon the local disease in the bone. 

Cod-liver oil, the hypophosphites, the various preparations of iron 
or other tonics may be given at certain times with benefit, but the con- 
tinuous administration of medicine during the years that are required 
to complete a cure is, of course, out of the question. 

Local Applications. Iodofoem. — Iodoform is supposed to exercise 
a direct germicidal action and also to stimulate the formation of the gran- 
1 Personal communication from Dr. David Bovaird. 



TREATMENT. 205 

illations that cast off or absorb the tuberculous products and then 
become transformed into fibrous tissue. At one time direct injection 
of the remedy into the bones was advocated, but this has now been 
abandoned, and its use is practically limited to the treatment of tuber- 
culous abscesses. Iodoform is ordinarily employed in an emulsion with 
glycerine or oil, 10 cc. of 10 per cent, mixture being injected at inter- 
vals of two or more weeks. Several deaths from iodoform poisoning 
have been reported, but injections of this quantity of the drug are ap- 
parently free from danger. 

Carbolic Acid. — Carbolic acid in dilute solutions was at one time 
injected into tuberculous cavities, but its use has been generally dis- 
continued because of the danger of poisoning. Eecently Phelps has 
advocated the use of pure carbolic acid in the treatment of tubercu- 
lous abscesses and sinuses. This is injected into the fistulse or into 
the abscess cavity, which has been opened, and is allowed to remain 
for about a minute, when it is neutralized by copious injections of al- 
cohol, after which the part is thoroughly cleansed by salt solution. 
Carbolic acid doubtless acts as a caustic, destroying the infected gran- 
ulations and stimulating the reparative processes. Other remedies of 
this class, for example, tincture of iodine, chloride of zinc, actual 
cautery and the like, are also used and in certain cases with benefit. 
In the treatment of tuberculous ulcerations ichthyol, balsam of Peru 
and iodoform are among the drugs employed. Balsam of Peru dis- 
solved in castor oil of a strength of about 10 per cent, as suggested 
by Van Arsdale, is a very satisfactory application. 

Venous Stasis — Bier's Treatment. — Bier's treatment of tuberculous 
joint disease was suggested by the observation of Rokitanski, that 
phthisis was uncommon in individuals suffering from disease of the 
heart when the mechanical obstruction was sufficient to cause venous 
congestion of the lungs. 

This treatment, by means of venous stasis, is conducted as follows : 
A rubber bandage is placed about the limb above the joint, under suffi- 
cient tension to interfere with the return of the venous blood ; and in 
order to limit the congestion to the diseased part, the limb is firmly band- 
aged with a flannel bandage up to the joint, from below. Between the 
two the tissues about the joint become swollen, the local temperature is 
increased and the color of the skin becomes bluish red. At first the 
congestion is continued for short periods only during the day, as it is 
somewhat painful. These are lengthened, until finally it may be ap- 
plied continuously. 

If the disease is active the treatment may hasten abscess formation, 
and if sinuses are present the discharge is usually increased for a time. 
The venous congestion is supposed to stimulate the formation of healthy 
granulations and their further transformation into fibrous tissue ; and 
according to the investigations of Hamburger, the serum of venous 
blood has a distinct germicidal property. The treatment may be ap- 
plied most conveniently at the knee and ankle joints, but if applied it 
should serve merely as an adjunct to mechanical protection. 



CHAPTER VI 



NON-TUBERCULOUS DISEASES OF THE JOINTS. 



Fig. 145. 



Syphilitic Disease of the Joints. 

In early infancy the characteristic syphilitic disease of the bones 
is a form of osteochondritis. Painful, sensitive swellings appear at 
the epiphyseal junctions, either as small, hard tumors or as general 
enlargements, resembling those of rhachitis. (Fig. 145.) As a rule 
several epiphyses are involved, more often those 
at the distal extremities of the bones of the lower 
limbs, and in these cases the pain and discomfort 
may induce an appearance of helplessness of the 
part called pseudo-paralysis. (Parrot.) In osteo- 
chondritis there is a multiplication and irregu- 
larity of the cartilage cells of the ossifying layer 
and premature calcification. As a result, the cir- 
culation is insufficient and necrosis of a part of the 
cartilage may follow, which, acting as a foreign 
body, sets up inflammatory 
changes in the adjoining 
parts. The process is 
shown by a zone of hard, 
dry yellow substance in the 
ossifying layer, adjoining 
which is an inflammation 
of the tissues of the newly 
formed bone which is in 
part transformed to granu- 
lation tissue. If the dis- 
ease is progressive ulcera- 
tion and suppuration may 
follow, the cartilage may be 
destroyed and the epiphy- 
sis may be separated caus- 
ing deformity and cessation 
of growth. The neighboring joint is usually involved in the disease. 
In the milder cases there is a simple sympathetic synovitis ; in the 
advanced class a destructive arthritis. In one case seen recently, the 
symptoms of pain on motion combined with slight effusion into several 
joints were present without the epiphyseal enlargement. The affection 
may be distinguished from rhachitis by the accompanying symptoms 





Suppurative syphilitic epiphysitis at lower ends of 
radius and tibia in an infant aged one month. The child 
died shortly after the drawings were made, and the epi- 
physes were found lying loose in purulent cavities. 
(Tubby.) 



SYPHILITIC DISEASE OF THE JOINTS. 



207 



of syphilis, by the irregularity of the epiphyseal involvements and by 
the age of the patient and the absence of the other symptoms of rhachitis. 

In the LATER MANIFESTATIONS OF HEREDITARY SYPHILIS, in which 

the bones in the neighborhood of the joint are involved in syphilitic 
osteoperiostitis, the joint may be sympathetically affected or the disease 
may actually perforate the joint. A slow, chronic, infiltrating gum- 
matous form of disease appearing in later childhood may simulate very 
closely the appearances of so-called white swelling. It is more com- 
mon at the knee, but other joints are often affected as well. 



Fig. 146. 



Fig. 14' 





Syphilitic osteo-periostitis of the tibiae resembling an- 
terior bow leg. This is the most characteristic manifes- 
tation of hereditary syphilis. 



Syphilitic disease. 



In the secondary stage of acquired syphilis, pain and swell- 
ing of the joints, resembling rheumatism, may be present, and in ter- 
tiary syphilis the joint may be involved in disease of the neighboring 
bones, or the joint itself may be primarily implicated. 

In most instances the joint affections of syphilis are explained by 
the history and by the other signs of syphilitic disease. Spina ventosa 
(Fig. 147), which is classed as one of the evidences of syphilis, is far 



208 NON-TUBERCULOUS DISEASES OF THE JOINTS. 

more commonly of tuberculous origin, as is illustrated by the statistics 
of Karewski, 1 of 157 cases, in which but three were due to syphilis. 

Syphilitic disease of the joints is very uncommon in orthopaedic 
clinics as compared with those of tuberculous origin. This is as 
might be expected, for not only is tuberculosis far more common than 
syphilis, but a very large proportion, according to Fournier, 77 per 
cent., of the syphilitic children are born dead or die shortly after birth. 
Even in those that survive, disease of the bones or joints in the form 
that could be confounded with tuberculosis, is uncommon as compared 
with its other manifestations. 

Some writers consider hereditary syphilis to be a very important 
predisposing cause of tuberculous disease, and believe that many cases 
classed as tuberculous are in reality syphilitic, even if no history or 
confirmatory signs of syphilis be present. There is no reliable evi- 
dence to support this view. The possibility of the syphilitic taint, re- 
mote or direct, should be borne in mind, and in doubtful cases appro- 
priate remedies should be employed ; but whether the disease of joint 
be syphilitic or not the same protective treatment is indicated that 
would be applied under other circumstances. 

GONORRHEAL ARTHRITIS. 

Synonym. Gonorrheal Rheumatism. — So-called gonorrhoeal rheu- 
matism is an inflammation of a joint caused by the presence of gono- 
cocci. It is said to complicate from two to five per cent, of all the 
cases of gonorrhoea, usually appearing in the later stages of that af- 
fection, and it is more common among those who are in a debilitated 
condition. 

Distribution. — In about 40 per cent, of the cases it is monartic- 
ular and the knee joint is most often involved. In 375 cases collected 
by Finger, the distribution was as follows : 2 

Knee 136 Shoulder 24 

Ankle 59 Hip 18 

Wrist 43 Jaw 14 

Finger joints 35 Other articulations 21 

Elbow 25 375 

Bennecke 3 has tabulated 78 cases recently under treatment. The 
78 cases occurred in 56 patients, of whom 18 were males, 38 females. 
The distribution was as follows : 

Knee 31 Shoulder '. 4 

Hip 8 Elbow 10 

Ankle 9 Wrist 6 

Other joints of foot 6 Fingers 4 

78 
Symptoms. — The affection is usually of a subacute character. 
The joint becomes swollen and there is discomfort, particularly weak- 

1 Chir. Krank. des Kindesalters. 

2 Taylor, Ven. Diseases, p. 263. 

3 Die Gon. Gelenkentzundung nach beob., der Chir. Univ. Klin, in der K. Charite 
zu Berlin. Hirschwald, Berlin, 1899. 



GONORRHEAL ARTHRITIS. 



209 



Fig. 148. 



ness, and stiffness on use ; but if the infection is more severe there 
may be local heat, pain and infiltration of the tissues with accompany- 
ing muscular spasm. 

Gonorrheal arthritis has been divided into three classes according 
to its symptoms and physical characteristics : The serous ; the sero- 
fibrinous ; the purulent. 

The SEEOUS form is, as 
its name implies, a simple 
effusion resembling other 
forms of subacute synovitis, 
although it is of a more 
chronic character. 

The SEROFIBRINOUS VA- 
RIETY is of a more serious 
character, the so-called plas- 
tic type of inflammation. In 
this form fibrin may be de- 
posited upon the cartilage 
which is afterwards organ- 
ized by the growth of vessels 
into it from the synovial 
membrane, a process which 
erodes the cartilage upon 
which'the granulations rest. 
The folds of the synovial 
membrane adhere to one an- 
other, the capsule is thick- 
ened and ligaments and ten- 
dons may be involved in 
the adhesive inflammation. 
These changes within and 
without the joint may se- 
riously impair its function 
after the cure of the active 
disease. 

The purulent form is 
uncommon ; it is similar in 
its characteristics to suppu- 
rative arthritis from other 
causes. It is attended by 
great local heat, pain and swelling and by constitutional disturbance. 

In orthopaedic clinics gonorrheal arthritis is usually seen in its later 
stages when the acute symptoms have subsided. In these cases, swell- 
ing and pain persist, in many instances, and in the more severe 
class motion is limited or the limb may be fixed in an attitude of 
deformity. An obstinate, monarticular, painful swelling of a joint- 
suggests gonorrhoea, and its presence or absence should always be de- 
termined, since the effective treatment of the primary cause is essential 
14 




Deformities resulting from infectious osteomyelitis. 



210 



NON-TUBERCULOUS DISEASES OF THE JOINTS. 



to the cure of the secondary affection of the joint. The same statement 
is true of painful, persistent affections of bursse and tendon sheaths, 
and of obstinate forms of weak foot. 

Treatment. — The treatment of the early stage of this form of 
arthritis is rest and compression with hot or cold applications as may 
seem to be indicated. If the symptoms are acute and if there is consti- 
tutional disturbance, the joint 
Fig. 149. should be aspirated, and if the 

examination shows the effusion 
to be sero-purulent, it should 
be treated by incision and 
drainage. In the chronic form 
also, when the capsule is dis- 
tended by the sero-fibrinous 
effusion, incision and removal 
of the contents is indicated. 

In the latter stages of disease 
of the ordinary subacute type, 
the treatment is directed to the 
absorption of the effused ma- 
terial within and without the 
joint, and to the restoration of 
functional activity. The use of 
hot air, massage, the hot and 
cold douche and the like are of 
service in stimulating the cir- 
culation. If the limb has be- 
come deformed, and if it be 
fixed by adhesions and by con- 
tractions, the distortion may be 
corrected by forcible manipula- 
tion under anaesthesia which 
will serve to rupture the adhe- 
sions as well. And it may be stated that this class of cases is the most 
encouraging from the standpoint of restoration of function by this means. 
If, however, the limb is fixed in the proper position it is well to 
postpone forcible measures until the effect of the massage and gentle 
passive movements have been observed. 

Functional use is the most effective treatment, and this is made 
possible by the employment of apparatus by which the exact amount of 
motion that the joint will allow without discomfort, may be permitted. 




Loss of growth following osteomyelitis of the tibia. 



Other Forms of Infectious Arthritis. 

Puerperal arthritis, resembling that caused by gonorrhoea may 
occur. It is usually of a more severe type as it is often caused by 
mixed infection. 

Arthritis Following Infectious Disease. — The joints may be 



ACUTE ARTHRITIS OF INFANCY. 211 

involved in the course of any infectious disease. A mild form of 
arthritis often involving several joints, is particularly common after 

DIPHTHERIA OR SCARLATINA. 

Localized and destructive forms of suppurative arthritis also occur. 
Arthritis following typhoid fever, is usually of a severe and destruc- 
tive type. Keen l has tabulated 84 cases. In 43 per cent, of these 
the hip joint was affected and in 40 per cent, spontaneous dislocation 
occurred. In a case treated recently at the Hospital for Ruptured 
and Crippled there had been a destructive arthritis of one hip joint, 
spontaneous displacement of the femur on the other side and secondary 
contractions at the knees and ankles, so that the patient was bedridden. 

Treatment. — The treatment in all forms of arthritis complicating 
diseases of this class, is to place the affected joint at rest, and to pre- 
vent the secondary distortions that lead to fixed deformities. 

Spontaneous dislocation which is comparatively common when the 
hip joint is suddenly distended with fluid, is not likely to occur unless 
the limb is flexed and adducted. This attitude should be prevented 
by the use of traction or support. 

The presence of pus is of course an indication for operative inter- 
vention, and in all doubtful cases the character of the effusion should 
be ascertained by aspiration. 



ACUTE ARTHRITIS OF INFANCY. 

Acute Epiphysitis. 

A form of acute suppurative arthritis primarily within the joint or 
more often secondary to disease of the neighboring epiphysis, is not 
uncommon in infancy. 

Etiology. — The disease may be caused by staphylococci, or strep- 
tococci, or by mixed forms of infection. In the early weeks of life it 
may follow infection of the umbilicus. It may be secondary to one 
of the exanthemata or to gonorrhoea, but in many instances the origin 
is not apparent. Falls or blows upon the part appear to be predis- 
posing causes. 

Townsend 2 tabulated seventy -three cases of acute arthritis, eighteen 
of which were personal observations. To these I am able to add 
twelve others, making a total of eighty-five cases. In sixty-four of 
these the infection was monarticular, in twenty-one more than one 
joint was involved. The distribution was as follows : 



Hip joint 45 53 per cent. 

Knee " 32 37 " 

Otherjoints 8 10 " 

The sex was specified in sixty-one cases. Males, thirty-eight ; fe- 
males, twenty-three. 

1 Surgical Complications and Sequels to Tvphoid Fever. 

2 Am. Jour. Med. Sci., Jan., 1890. 



212 NON-TUBERCULOUS DISEASES OF THE JOINTS. 

Symptoms. — If the infection is severe there is immediate local heat, 
redness, swelling and oedema, great pain and corresponding constitu- 
tional disturbance. But in many instances the local and general symp- 
toms are less marked and several weeks may elapse before the patient 
is brought for treatment. 

Treatment. — The treatment is of course free incision and drainage. 
The part must be supported during the active stage of the disease ; an 
apparatus is usually required to prevent deformity or to support the 
weak limb when the patient begins to walk. 

Prognosis. — If the arthritis is a primary disease within the joint com- 
plete recovery may follow evacuation of the pus, but as a rule the neigh- 
boring epiphyseal junction is diseased, suppuration is prolonged and a 
part of the epiphysis is destroyed before the disease comes to an end ; 
thus subluxation or displacement with subsequent deformity and loss of 
growth are the usual results of this form of disease. At the hip joint, 
for example, the laxity of the ligaments and the upward displacement 
of the femur that follow destruction of the head of the bone, cause 
symptoms that are often mistaken for those of congenital dislocation. 

In some of the cases there is, in addition to the arthritis, an osteo- 
myelitis of the shafts of one or more of the bones. These cases are 
usually fatal, or if the patient survives, there is usually necrosis of the 
affected bones and consequently extreme deformity. 

In the cases reported by Townsend the death rate was in the monar- 
ticular form, eighteen per cent.; in the multiple form, seventy -three 
per cent. 

Acute Tuberculous Arthritis. — In early infancy forms of acute 
tuberculous disease, especially at the knee joint, may simulate closely 
infectious arthritis. The knee may be swollen, hot and sensitive to 
pressure and the onset may be sudden and accompanied by constitu- 
tional disturbance. Such cases are more often observed in the chil- 
dren of mothers in whom there is advanced disease of the lungs. 

Localized Infectious Osteomyelitis. 

In older subjects localized osteomyelitis in the neighborhood of a 
joint may simulate tuberculous disease. The onset of the affection is 
however more abrupt, the surrounding tissues are infiltrated and the 
symptoms are usually more acute than in the latter affection. In such 
cases operative intervention is indicated. 

Osteo- arthritis. 

Synonyms. — Arthritis Deformans, Rheumatoid Arthritis. 

Osteo-arthritis is a chronic destructive disease of the joints re- 
sembling rheumatism somewhat in its distribution and clinical history. 

Pathology. — The disease appears to begin in the cartilage which 
becomes fibrilated and destroyed in the parts subjected to greatest 
pressure, while it is thickened and heaped up into irregular layers at the 
periphery, as if under the influence of pressure it had been squeezed out 



OSTEO-ARTHRITIS. 



213 



from the interior of the joint. (Fig. 150.) The process is supposed to 
consist in a multiplication of the cartilage cells which in the free por- 
tion of the cartilage escape into the joint while in those parts covered by 
synovial membrane they are retained. When the cartilage disappears 
the bone deprived of its natural protection is worn away, and under 
the influence of pressure and friction it becomes increased in density 
and hardness, "eburnated." Meanwhile the hypertrophied cartilage 
at the periphery becomes in part ossified. Thus the contour of the 
bones and their mutual relation to one another are changed. The 
synovial membrane becomes hypertrophied and its villi, some of which 
may contain cartilaginous no- 
dules, project into the joint in FlG - 15 °- 
shaggy fringes. These may be 
detached from time to time and 
may form loose bodies within 
the capsule. The synovial 
fluid may be greatly increased 
in quantity, distending the 
capsule or, communicating 
with bursse, it may form cysts, 
as is sometimes observed at 
the knee joint. But more com- 
monly the fluid is decreased in 
amount. The ligaments are 
weakened and destroyed and 
the tendons about the joint 
become adherent to their 
sheaths and to the neighboring 
tissues. The muscles atrophy 
and become contracted and 
structurally shortened in ac- 
commodation to the deformity. 

Etiology. — The subject is 
as yet very imperfectly under- 
stood, and the terms osteo- 
arthritis and rheumatoid ar- 
thritis, which are usually con- 
sidered as synonymous, probably include a number of pathological con- 
ditions. The etiology is uncertain. Malnutrition, exposure to cold 
and wet, infectious diseases and a peculiar condition of the nervous 
system are considered as predisposing causes, and recently it has been 
claimed that the disease is of germicidal origin, but this is doubtful. 
Injury may be a predisposing, as it certainly is an exciting, cause in the 
monarticular form. 

Varieties. — Osteo-arthritis may be divided, from the clinical stand- 
point, into the multiple and the localized forms. 

Multiple osteo-arthritis may be acute, subacute or chronic. 

In the acute variety the disease may resemble rheumatism, but the 






Arthritis deformans, from the Museum of the College 
of Physicians and Surgeons, New York. 



214 NON-TUBERCULOUS DISEASES OF THE JOINTS. 

ordinary form is the subacute or chronic, which may progress slowly, 
involving one joint after another until the patient may be crippled by 
the limitation of motion in the joints, and by the secondary distortion 
of the limbs. 

The affection is far more common among females than males, and it 
usually begins in early middle life, although it is not particularly in- 
frequent in childhood. In one case, seen at the Hospital for Ruptured 
and Crippled, the patient was less than four years old, and several 
patients have been treated in the wards who were less than ten years 
of age. 

In 500 cases of the multiple form tabulated by Garrod, 1 the distri- 
bution was as follows : 



The hands 


were 


involved 


in 86 pei 


cent 


of the cas 


' ' knees 


a 




a 


" 60.6 


a 


a a 


" feet 


a 




i i 


" 34.4 


a 


a a 


' l ankles 


a 




it 


" 27.4 


a 


a a 


1 ' wrists 


a 




i i 


" 26.6 


a 


a a 


1 ' shoulders 


il 




a 


" 25 


a 


a a 


1 ' elbows 


a 




t t 


" 25 


a 


a a 


" hips 


a 




it 


" 14.6 


a 


a a 


^Temp. max. artic. 




a 


25 


a 


a a 


tDervical spine 






a 


35 


i i 


a a 


Dorsal spine 






a 


3 


a 


a a 


Sterno-clavicular ai 


tic 




4 


a 


a a 



Another form of osteo-arthritis of comparatively slight importance is 
that in which the disease is confined to the joints of the fingers. The 
bases of one or more of the distal phalanges become enlarged (He- 
berden's nodosities) and the fingers become somewhat stiff and painful. 
Gradually other phalangeal joints become involved until the fingers 
become deformed and function is somewhat interfered with, although 
never to the extent that is observed in the multiple form in which the 
fingers are dislocated and distorted. 

As has been stated, the disease is usually progressive, periods of 
quiescence alternating with exacerbations of pain and discomfort, at 
which times the disease progresses. 

The Localized Form. — The localized form of osteo-arthritis, al- 
though similar in its pathological appearances, differs from the mul- 
tiple variety in that it is more common in men than in women, and 
that injury appears to have a distinct influence in its causation. 

The affection may be limited to one of the large joints, the hip, the 
knee or the shoulder, while the hands, that are almost invariably in- 
volved in the multiple form, remain free from disease. 

The Atrophic Form. — In the description of the pathology of 
osteo-arthritis it has been stated that the disease is characterized by 
proliferation of cartilage, and by hypertrophy combined with destruc- 
tion of the bone. There is, however, another variety of disease re- 
sembling this form closely in its symptoms, in the quality of the 

1 Twentieth Century Practice. 



TREATMENT. 215 

patients who are subject to it and in its distribution, being both multi- 
ple and monarticular, but differing from it in its pathological anatomy. 
In this form there is no hypertrophy but an actual atrophy of the bone 
entering into the formation of the joint. In the active stage of the 
disease the joints are swollen, infiltrated and thickened, but this 
thickening is practically limited to the soft tissues outside the joint, 
and after the acute stage has passed the stiffened joints may be actually 
smaller than before. Thus osteo-arthritis includes two varieties of dis- 
ease from the standpoint of the pathological characteristics, the hyper- 
trophic and the atrophic. 

Goldthwait 1 suggests that the term osteo-arthritis might be limited 
to the hypertrophic form, while the other variety, characterized by 
stiffening of the joints without marked destruction or lateral displace- 
ment, might be classified as rheumatoid arthritis. It is doubtful, 
however, if a sharp distinction can be drawn between the two. In 
childhood, for example, there may be great destruction and displace- 
ment of the finger joints without hypertrophy which, in fact, is almost 
never observed in this class. Again in the early stage of osteo-arthri- 
tis it is practically impossible to distinguish the hypertrophic from the 
atrophic form. It is possible, also, that the two varieties may be com- 
bined in the same individual, or that either form may be complicated 
by ordinary rheumatism. 

Symptoms. — The symptoms are discomfort and pain more marked 
in damp weather or after over-exertion ; stiffness on changing from rest 
to activity and creaking sensations apparent on palpation. Motion 
is restricted by muscular spasm and contraction and by the mechan- 
ical effects of the disease within and without the joint, and finally the 
limb may become fixed in an attitude of deformity. In the spine, 
the deformity is usually a long posterior curvature and the vertebrae 
are firmly fixed by growth of periosteal bone, or if the cervical region 
is diseased the head may be distorted. (See spondylitis deformans.) 
At the hip joint there is wearing away of the head of the. bone and 
upward enlargement of the acetabulum, so that a form of pathological 
coxa vara or subluxation appears, and the limb is usually somewhat 
flexed and adducted. This condition is sometimes mistaken for frac- 
ture of the neck of the femur, especially when the symptoms have 
been aggravated by injury. A similar pathological condition may oc- 
cur at the shoulder. 

Treatment. — The treatment should be directed to improving the gen- 
eral condition of the patient and protecting him from exposure to sudden 
changes in temperature. Locally the disease may be favorably influ- 
enced by massage, by hot air, by static electricity and the like, meas- 
ures which doubtless serve to improve the local nutrition and thus the 
resistance of the affected part. The application of the actual cautery 
and the protection assured by flannel bandages, add greatly to the com- 
fort of the class of patients seen in hospital practice. 

If deformity is present it may be overcome if necessary by forcible 
Boston Med. and Surg. Jour., Jan., 1897. 



216 



NON-TUBERCULOUS DISEASES OF THE JOINTS 



manipulation under anaesthesia, after which the improved position may 
be assured by proper apparatus. This treatment is much more useful, 
according to Gold th wait, in the atrophic than in the hypertrophic form 
of the disease. In cases in which the anchylosis is resistant or when 
the joint is disabled it may be excised. This operation has been per- 
formed with success at the knee ; and by it motion has been restored 
at the elbow in cases reported by Collinson, Bannatyne and Southam. 1 
In one case treated at the Hospital for Ruptured and Crippled the 
function of the jaw was restored completely by excision. 

In the localized form, apparatus to protect the part from strain and 
injury and to prevent deformity, is sometimes of great service. And 
in certain instances exploration of the joint which would permit of the 
removal of hypertrophied tissue might be of service. 



Haemophilia — Hemarthrosis. 

Hemorrhage into a joint may occur in a so-called " bleeder." In 
this class, practically limited to the male sex, the knee joint is most 

often involved. As a rule it 
Fig. 151. is the result of injury and if 

the peculiarity of the patient 
is known, the nature of the 
effusion may be suspected. 
In some instances there is no 
history of traumatism and 
the swelling may be accom- 
panied by fever. This is 
probably the effect of the 
hemorrhage rather than its 
cause. 

The peculiar interest in 
the affection, aside from the 
importance of a proper diag- 
nosis, lies in the fact that the 
further organization of the 
effused blood may cause 
symptoms, and changes about 
the joint, that may be mis- 
taken for those of tubercu- 
lous disease. There may be, 
for example, persistent swell- 
ing, thickening of the tis- 
sues, limitation of motion and 
deformity combined with more or less weakness and discomfort. These 
symptoms are explained by the irritation of the effused blood and by 
its further absorption and organization which necessitates the formation 
and growth of new blood vessels ; practically a granulation tissue is 

1 Lancet, Nov. 4 and Dec. 9, 1899. 




^Charcot's disease of the knee joint. 



CHARCOT'S DISEASE. 217 

formed that may erode the cartilage upon which the fibrinous deposits 
rest. These secondary changes resemble the early stage of osteo-arthritis. 
Treatment. — The treatment is rest and protection. Several deaths 
have been reported from hemorrhage after operative intervention in 
cases in which the affection had been mistaken for tuberculous disease. 

Hemarthrosis. 

Hemorrhage into a joint caused by traumatism, complicating synovial 
effusion, is sometimes followed by the same persistence of symptoms, 
and it may be, by the destructive changes that result from the effusion in 
hemophilia. This suggests the advisability of incision and removal of 
the blood clot, in order to relieve the part of this unnecessary process. 

Scorbutus — Scurvy. 

This affection is sometimes attended with hemorrhage into and about 
the joints. It will be considered in connection with infantile rhachitis. 

Charcot's Disease. 

Charcot's disease is a form of arthritis which is secondary to loco- 
motor ataxia. 

Pathology. — It resembles somewhat in its pathology osteo-arthritis. 
The cartilage degenerates and, together with the underlying bone, is 
worn away by the movements of the limb. Accompanying the destruc- 
tive process there is an exaggerated and irregular formation of carti- 
lage and bone about the periphery of the joint. The synovial mem- 
brane is hypertrophied and may be covered in places with calcareous 
plates ; the contents of the joint is usually increased in quantity. 

The joint disease usually appears early in the course of locomotor 
ataxia often before its existence is suspected and it is sometimes caused 
by injury. 

Charcot's disease is said to affect from five to ten per cent, of the 
ataxic patients ; it is more common in the lower extremity and one or 
more joints may be involved. In the cases tabulated by Flatow the 
distribution was as follows : 

Knee 60 ; in 13 cases both knees. 

Foot 30; " 9 " " feet. 

Hip 38; " 9 " " hips. 

Shoulder 27; " 6 " ' " shoulders. 1 

Symptoms. — The symptoms are the swelling due to the effusion, 
laxity of the ligaments and deformity. There is but little pain and 
the patient's chief complaint is of the weakness and distortion of the 
limb. In certain cases the progress of the affection is very rapid and 
the destruction of bone may be so extensive that there is an actual 
luxation at the affected joint. 

Diagnosis. — If the patient is known to have locomotor ataxia the 
diagnosis will be evident, and in any case the peculiar enlargement 
Deutsche Chir., L. 28, 19C0. 



218 NON-TUBERCULOUS DISEASES OF THE JOINTS. 

and thickening of the tissues, together with its excessive laxity of the 
ligaments, characteristic of this affection, which has been called a 
caricature of osteo- arthritis, should call attention to the disease of the 
spinal cord. 

Treatment. — The treatment of the disease is efficient support (Fig. 
152) for the joint, to prevent progressive distortion. Excision of the 
knee has been performed, but in many cases the bones have failed to 
unite, and on this account the operation is contraindicated. 

Disease of joints secondary to other forms of disease of the 
nervous system may occur. It is most common as a complication of 
syringomyelia, in which, in contrast to locomotor ataxia, the joints of 
the upper extremity are far more often involved than of the lower. 

In Schlesinger's cases the distribution was as follows : l 

Shoulder 29 

Elbow 24 

Wrist 18 

Hip 4 

Knee 7 

Foot 7 

Other joints 8 

97 

In all forms of joint disease secondary to disease of the nervous 
system, the influence of injury on the ill-nourished or ill-protected part 
is recognized in the causation and in the progress of the disease. 

This indicates the principles of local treatment. 

Anchylosis. 

Anchylosis implies fixation in an attitude of deformity, and the term 
should be restricted to practical fixation caused by tissue changes 
within or without a joint, but it is often incorrectly applied to limita- 
tion of motion such as may be caused, for example, by muscular spasm. 

Etiology and Pathology. — Anchylosis may be the result of actual 
union of two bones whose cartilages have been destroyed, a synostosis. 
This is sometimes called true, as distinguished from false or fibrous 
anchylosis. 

It may be caused by adhesions between the folds of synovial mem- 
brane, by adhesions and contractions of the capsular and other liga- 
ments, by adhesions between the tendons and their sheaths, by the 
general adhesions and contractions caused by burrowing abscesses 
and by the retraction and structural shortening of muscles when 
the deformity has persisted for a sufficient time. It may be caused 
also by fractures or dislocations or by marginal exostoses. 

Anchylosis is usually secondary to an inflammatory affection of the 
joint during which the adhesions have formed, within and without the 
capsule, and if deformity has been allowed to persist the muscles may 
have become atrophied and structurally shortened as well. 

1 Die Syringomyelie, Wien, 1895. 



ANCHYLOSIS. 



219 



Prevention and Treatment. — The danger of anchylosis may be 
lessened by the proper treatment of the disease of which it is a result. 
In tuberculous disease, for example, motion may be preserved in many 
instances by efficient protection, by which the area of the disease is 
restricted and its destructive effects 
checked. In this class of cases the joint 
should be fixed, during the progressive 
stage of the disease, in the attitude in 

Fig. 152. 



Fig. 153. 





A useful form of brace for weak knee. 
Campbell brace. (Shaffer.) 



The 



Anchylosis at the hip, showing 
masses of new bone. ( From the Mu- 
seum of the College of Physicians 
and Surgeons.) 



which anchylosis, if it be unavoidable, will least inconvenience the patient. 

Formerly it was believed that prolonged fixation of a tuberculous 
joint would of itself induce anchylosis, but now that it is known that 
final limitation of motion is dependent upon the severity and the dura- 
tion of the disease, prolonged rest is believed to be the most efficient 
means of assuring final motion. 

In this class of cases, when the disease is cured, functional use will 



220 NON-TUBERCULOUS DISEASES OF THE JOINTS. 

ordinarily restore all the motion of which the part is capable. In 
other inflammatory affections of the joint which are usually of infectious 
origin, the violence of the acute process may be restrained by rest, or 
by the removal of the contents of the joint if the infection is severe. 

Passive Motion. — When the acute symptoms have subsided the ab- 
sorption of the plastic material may be hastened by massage, the hot air 
bath and the like, and by carefully regulated passive and active motion. 
In the final stage, when there is no longer evidence of active disease, 
passive movements under anaesthesia may be of service in breaking 
adhesions, especially if these are without the joint. Passive movements 
that cause persistent discomfort or pain, which are often employed in 
the treatment of stiff joints, even when the disease is active, are abso- 
lutely contraindicated. If however, the limb during the course of the 
disease has become deformed, it should be restored to its proper position 
as soon as possible even though force is required. This treatment is in- 
dicated in order to prevent secondary retraction of the muscles and fasciae. 

Forcible Correction. — The class of cases, in which the limb has 
become fixed in deformity, is the most favorable class on which to per- 
form so-called brisement force because the rectification of deformity is 
always indicated, and in accomplishing this there is always the pros- 
pect of regaining a certain degree of motion. If, however, there is no 
deformity the advisability of forcible motion will depend on the char- 
acter of the preceding disease, as well as upon the condition of the joint. 
It is rarely advisable to disturb a tuberculous joint or at least not until 
long after the cure of the disease, but if the anchylosis has followed 
infectious arthritis of a mild form, or monarticular rheumatism, forci- 
ble manipulation may be attempted. If under gentle manipulation the 
adhesions give way suddenly, allowing free motion, the prognosis is 
good, but if there be a peculiar elastic continuous resistance, as when 
there are extensive adhesions within the joint, there is little likelihood 
of attaining motion by this means. If but slight force has been ex- 
erted there is usually but little reaction, and massage and passive motion 
may be employed at once ; but in other instances the manipulation is 
followed by swelling and pain, and until these symptoms have subsided 
fixation may be indicated. Afterwards, passive movements within the 
range that is practically painless, and functional use, when the part is 
protected by apparatus which limits the range of motion to the painless 
area, are of service. The X ray is of service in indicating the con- 
dition of the joint, but the history of the disease and the physical ex- 
amination which shows its destructive effects, is of more value. In 
some instances operative exploration of the joint may be indicated. 
This permits the removal of exostoses or displaced fragments of bone 
after fracture that may limit motion mechanically. True bony anchy- 
losis in the lower extremity admits of no remedy as far as the restor- 
ation of joint function is concerned, although the symmetry of the limb, 
if it be deformed, may be restored by osteotomy. But in the upper 
extremity, motion may be gained by excision of the joint and in some 
instances this is advisable. 



CHAPTER VII. 
TUBERCULOUS DISEASE OF THE HIP JOINT. 

Synonyms. — Hip Disease, Morbus Coxse. 

Hip disease is a chronic destructive disease that results in loss of 
function and deformity. At one time a number of pathological proc- 
esses and even simple deformity (coxa vara) were included under the 
title, but it is now limited to tuberculous disease. 

Pathology. — Tuberculous disease of the hip joint usually begins in 
several minute foci in the neighborhood of the epiphyseal cartilage of 
the head of the femur. Here the circulation is most active and here 

Fig. 154. 







i 

Section of the hip joint at the age of six years. (Schuchardt. ) 

the newly formed bone is least resistant. Thus the bacilli, carried by 
the blood, are more often deposited at this point where, under favoring 
conditions, induced it may be by slight traumatisms, the disease is es- 
tablished. These foci coalesce and an area of infected granulations 
replaces the normal structures. If the local resistance is sufficient, the 
disease may be confined to the interior of the bone, but in most in- 
stances it gradually forces its way into the joint, and the granulation 
tissue spreading under and over the cartilage, destroys it in its progress. 
The lining membrane of the joint becomes involved in the disease and 
finally the adjoining surface of the acetabulum as well. In a certain 



222 



DISEASE OF THE HIP JOINT. 



Fig. 155. 



indeterminate number of cases, the tuberculous process begins about 
the epiphyseal junctions in the acetabulum, and primary disease of the 
synovial membrane may occur, although this is certainly uncommon in 
childhood. 

From the clinical standpoint, primary disease of the acetabulum may 
be inferred when the patient is particularly susceptible to movements of 
the trunk, or when lateral pressure on the pelvis causes pain ; or when 
a Roentgen picture shows greater erosion of the acetabulum than of the 
head of the femur. (Fig. 168.) There are certain cases also, in which 
the symptoms of the disease are slight and in which the swelling of the 
joint is well marked ; in such cases it is probable that disease of the 

synovial membrane is present, 
unaccompanied by marked in- 
volvement of the head of the 
femur or of the acetabulum. As 
a rule, however, the symptoms 
may be best explained by pri- 
mary disease of the head of the 
femur. 

While the tuberculous process 
is still confined within the bone, 
the joint shows evidences of 
sympathetic irritation ; the syno- 
vial membrane is congested and 
the fluid within the joint is 
increased in quantity. These 
changes become more marked 
as the disease progresses, the 
membrane becomes thickened 
and granular, and adhesions be- 
tween its folds lessen the capacity 
of the joint. Thus, if the ad- 
vance of the tuberculous process 
has been retarded by efficient 
protection, it may involve but a 
small part of the former area of 
the joint when perforation occurs. 
An amount of tuberculous fluid, 
large enough to be diagnosticated 
as abscess, is present in about 
half the cases. This fluid usually 
finds an exit from the capsule into the tissues of the thigh, but 
occasionally it may pass through the acetabulum into the pelvic cavity. 
In rare instances the disease within the head of the femur may not 
enter the joint, but may make an opening in the neck outside the cap- 
sule, or it may even perforate the shaft of the femur. In such cases, 
the joint is, in most instances, finally involved unless the disease is re- 
moved by surgical means. 




Wandering of the acetabulum" 
(Krause. Deutsche Chir. 



in hip disease. 
L. 28 a.) 



PATHOLOGY. 



223 



If the disease involves the neck of the bone it may so weaken its 
structure that the angle with, the shaft is lessened, a form of coxa 
vara ; or the head of the bone may be separated at the epiphyseal car- 
tilage, with consequent upward displacement of the trochanter. 

In by far the larger number of cases the joint is perforated and the 
head of the bone and the acetabulum are involved to a greater or less 
degree. In such instances the destructive effects of the disease are in- 
creased by the pressure and friction of the softened bones on one 
another, aggravated by the spasm of the surrounding muscles. Thus 

Fig. 156. 




Erosion of the head of the femur and of the upper border of the acetabulum, 
bone (osteophytes) about the acetabulum. 



Formation of new 



at the upper margin of the acetabulum and the inner and upper surface 
of the femur, there is greater loss of substance than elsewhere. (Fig. 
156.) 

The appearances in advanced cases of this type, as seen at operation 
or autopsy, may be summarized somewhat as follows : The head of 
the femur is deeply eroded, its cartilaginous covering has practically 
disappeared or is in part still adherent in necrotic shreds. It lies in 
sero-purulent fluid, surrounded by the gelatinous necrotic granulations 
that line the capsule and partly fill the enlarged acetabulum. In cer- 
tain instances the pelvic bones may be diseased or the acetabulum may 



224 TUBERCULOUS DISEASE OF THE HIP JOINT. 

be perforated (Fig. 158), or the shaft of the femur may be involved. 
Occasionally the disease may be from the first of an acute destructive 
type whose course is but little influenced by treatment, but in the ma- 
jority of cases the progress of the disease, and its destructive effects, 
may be greatly modified by protection of the joint. 

In the natural cure of the disease the focus, if it be small, may be 
absorbed and replaced by scar-like tissue ; or the products of the dis- 
ease may be separated from the healthy parts, and discharged by ab- 
scess formation. In other instances, a part in which the disease is 
still active may be inclosed within the newly formed tissue. Here the 







Fig. 157. 












w 


' ■*?m 








9 


MmkHk- 


fcAM' 


*t 


ff^J| 


m mw **. Mm 













Erosion of the head of the femur and of the upper margin of the acetabulum. A, anterior superior 
spine ; B, anterior inferior spine. 

process may remain quiescent or it may cause relapse, many years after 
the apparent cure of the disease. Or portions of necrosed bone, in- 
closed within the capsule, may prolong suppuration after the tubercu- 
lous disease has disappeared. 

Etiology. — The etiology of tuberculous disease is discussed in Chap- 
ter Y. 

Relative Frequency. — Tuberculous disease of the hip joint is the 
most common and the most important of the affections of the joints, 
ranking second to Pott's disease. In a total of 7,845 cases of tuber- 
culous disease treated in the out-patient department of the Hospital for 
Ruptured and Crippled during the past fifteen years, 1885-1899, 3,203 
were Pott's disease ; 2,230 were hip disease, while the remaining 2,408 
cases included all the other joints. 



SYMPTOMS. 



2£5 



Age. — Hip disease is essentially a disease of early childhood, although 
no age is exempt. In a series of 1,000 consecutive cases of hip dis- 
ease tabulated for me by Dr. D. D. Ashley, assistant in the depart- 
ment, 88.1 per cent, of the patients were in the first decade of life, and 
45.6 per cent, of these were from three to five years of age inclusive. 



Age at Incipiency. 



Less than 1 year 




9 


Between 1 and 2 


rears 


39 


<< 


2 ' 


3 


n 


107 


a 


3 ' 


4 


it 


155 


it 


4 ' 


5 


it 


158 


a 


5 < 


6 


n 


139 


a 


6 < 


7 


tt 


90 


a 


7 < 


8 


a 


51 


it 


8 ' 


9 


a 


51 


n 


9 ' 


10 


a 


40 


a 


10 '' 


11 


a 


33 


it 


11 < 


12 


a 


19 


a 


12 < 


13 


a 


18 


it 


13 ' 


14 


" 


23 


it 


14 ' 


15 


" 


7 


i i 


15 ' 


16 


it 


8 



Between 16 


md 17 years 11 


it 


17 


" 


18 ' 


< 4 


" 


18 


" 


19 ' 


5 


" 


19 


ti 


20 ' 





a 


20 


" 


21 ' 


3 


a 


21 


" 


22 ' 


3 


it 


22 


" 


23 ' 


1 


it 


23 


" 


24 ' 


2 


it 


24 


" 


25 ' 


3 


1 1 


25 


ti 


26 ' 


1 


" 


26 


" 


27 ' 


1 


it 


27 


it 


28 ' 


1 


it 


28 


11 


29 < 


1 


n 


30 


" 


33 ' 


' 4 


it 


33 


" 


36 ' 


1 


Age not stated 




12 










1,000 



Sex. — Sex exercises but little influence although the disease is 
slightly more common among males than among females. In the 
1,000 cases referred to, 553 (55.3 per cent.) were in males, 447 were 
in females. 

In 3,307 cases treated at the Fig. 158. 

same institution, 53 per cent, 
were in males. 

Side Affected. — In disease 
of this as of other joints, the 
right is somewhat more often 
affected than the left. In the 
1,000 cases 506 were on the 
right side, 483 were on the left 
and in 11 cases both joints 
were involved. In a larger 
number of cases treated in the 
department, 53 per cent, were 
of the right joint. 

Symptoms. — Tuberculous 
disease of the hip joint is a 
chronic, insidious affection 
characterized by occasional ex- 
acerbations of more acute 
symptoms that are induced by 
over-strain or injury, by a more 
rapid advance of the destructive process, or by infection with pyogenic 
germs. In the early stage of the disease the joint is simply sensitive, 
and the symptoms vary according to the activity of the disease, which 
15 




Erosion of the head of the femur and destruction of 
the acetabulum. 



226 DISEASE OF THE HIP JOINT. 

may increase the tension within the bone ; the susceptibility of the 
patient and the strain to which the weakened part is subjected. This 
sensitiveness is shown by the involuntary adaptation of the body to 
the weakness of the affected part, or as popularly expressed, the pa- 
tient favors the leg. 

The important symptoms of disease of the hip joint, in the sense of 
attracting attention to the affection, are pain and limp. Of the two, 
pain is much the less significant. Hip disease is by no means a pain- 
ful disease, and although patients are often brought for treatment be- 
cause of pain, it is very evident, on examination, that the disease must 
have existed long before the acute exacerbation called attention to its 
serious character. Even in cases in which the disease is far advanced 
in the destructive stage, one may be assured that the patient has never 
complained of pain. 

Pain. — The characteristic pain of hip disease is "pain in the knee," 
just as the pain of Pott's disease is referred to the more important 
distribution of the nerves, whose filaments are irritated by the local 
process. The hip joint is supplied by the anterior crural, the sciatic 
and obturator nerves, but the pain is more often referred to the dis- 
tribution of the last, thus to the inner side of the knee. Pain so per- 
sistently referred to the knee is misleading, and patients are often 
treated for obscure troubles in this joint long after an examination 
of the hip would have made the diagnosis evident. 

Direct local pain and sensitiveness at the hip are unusual, unless 
the disease is acute in character or unless the tissues overlying the 
joint are implicated, as in abscess formation. The pain of hip disease 
is induced by sudden or unguarded movements, or by injury ; therefore, 
in many instances, it is rather an occasional than a constant symptom. 

Night Cry. — Pain at night is of importance, as it more often attracts 
attention than the occasional complaint of discomfort during the day. 
It is a common symptom when the disease is at all acute in character 
and it is often present when pain, during the period of activity, is ap- 
parently absent. It may be inferred, as an explanation of this symp- 
tom, that the joint gradually becomes more sensitive under the strain 
of use during the day, and that the relaxation of the voluntary and in- 
voluntary protection of the muscles allows sudden movements that ex- 
cite spasmodic muscular contractions, which force the sensitive parts 
against one another. This causes a sharp cry. If the disease is acute, 
the child is usually awakened and is found holding the thigh with the 
hands or pressing upon the limb with the other foot, the evidence of 
pain being unmistakable. In the less sensitive conditions the patient 
does not wake after crying out, but simply moans or is restless for a 
time. If awakened it makes no complaint of pain and the cry is sup- 
posed to be caused by a " bad dream." This cry may be repeated 
several times, more often in the early part of the night. 

Limp. — The limp is the most important of what may be classed as 
the preliminary signs of the disease. A limp is a change in the rhythm 
of the gait, a long step alternating with a shorter step. It is evident 



SYMPTOMS. 227 

that any interference with the function of the limb will cause this ir- 
regularity which can be concealed or diminished only by accommodat- 
ing the normal member to its disabled fellow. Thus an inequality in 
length, or a limitation of motion in the joint, or distortion or weak- 
ness or pain, may cause a a irregular gait, and several of these factors 
may be combined in the causation of the final disability of hip disease ; 
but in the early stage the limp is due rather to sensitiveness than to 
any marked restriction of function. Thus the patient favors the joint 
bv resting on the limb for a shorter time than on its fellow, and by 
bearing more weight upon the front of the foot than upon the heel. 
If the joint is more sensitive, the patient may bear practically all the 
weight upon the front of the foot, slight plantar flexion at the ankle 
being combined with slight flexion at the knee and hip ; thus the jar 
of direct impact of the heel upon an extended leg, is avoided. 

The limp is a very constant symptom of hip disease that is more or 
less noticeable according to the character of the disease ; it is even 
subject to daily variations in the same patient, being, as a rule, more 
apparent in the morning or on changing from an attitude of rest, than 
during activity. In the early stage of the disease the limp may be even 
intermittent, although it is probable that in most instances some change 
from the normal gait might be detected by a practiced eye. 

The other symptoms of disease of the hip joint are more properly 
physical signs that become evident on examination. These are : 
Stiffness, distortion, change of contour of the hip, atrophy. 

Stiffness, due to reflex muscular spasm, is by far the most impor- 
tant sign of the disease. It is the instinctive expression of the in- 
ability of the joint to perform its full function and especially to al- 
low the full range of motion which puts more strain upon the bones 
and the other components of the joint. It is the first and the last 
sign of disease ; it probably precedes the limp and it remains long 
after pain has ceased to be a symptom, and until repair is complete. 
Reflex muscular spasm limits motion in every direction to a 'greater 
or less degree. In the early stage of the disease the motion, whether 
voluntary or passive, may be perfectly free throughout three-fourths of 
its normal range, but when the limit allowed by the muscular protec- 
tion is reached, motion is checked by a peculiar elastic resistance. If 
an attempt is made to force the limb beyond the limit in any direc- 
tion, the entire body follows the movement. The contraction of the 
surrounding muscles, including those of the trunk even, may be ap- 
preciated by the eye and by the hand, and the expression of the pa- 
tient's face shows that the manipulation causes discomfort. 

The degree of muscular spasm is in proportion to the sensitiveness 
of the joint rather than to the area of the destructive disease. Thus 
it may vary from day to day and even from hour to hour, and in the 
acute exacerbations of the disease motion may be for a time so abso- 
lutely restricted as to simulate anchylosis. 

Reflex muscular spasm is an infallible sign of a sensitive joint ; it 
is, of course, a symptom not confined to the tuberculous process, but 



228 TUBERCULOUS DISEASE OF THE HIP JOINT. 

unless it be the direct effect of injury it shows the presence of disease, 
and if this disease be chronic and confined to a single joint it is, in 
childhood at least, almost always tuberculous in character. In the 
early stage of hip disease the restriction of motion is caused almost 
entirely by reflex muscular spasm, as is shown by the fact that when 
the patient is anaesthetized the range of motion becomes practically 

Fig. 159. 



The stage of apparent lengthening. Fixed abduction of 45°. When the anterior superior spines 
are on the same plane, as in the illustration, the deformity is evident. (See Fig. 160. ) 

free. In the later stages, however, motion is still further restrained 
by adhesions and contractions, within and without the joint. 

Distortion of the Limb. — Persistent reflex muscular spasm is always 
accompanied by a certain change in the attitude of the limb, slight 
flexion being the earliest indication of distortion in disease of the hip, 
as at every other joint. With this flexion there is usually abduction 
and slight outward rotation of the limb. 



SYMPTOMS. 



229 



Flexion, Abduction and Outward Rotation — Apparent 
Lengthening. — This is the passive attitude or the attitude of rest 
in the normal condition, and in disease it shows the instinctive adap- 
tation of the limb to a sensitive joint which is still capable of a certain 
amount of work. The limb, although still in use, is reduced in activity, 
the flexion lessens the direct jar and the abduction throws the limb aside, 



Fig. 160. 



Fig. 161. 





Stage of apparent lengthening. When 
the distorted limb is brought to the median 
line the pelvis is so tilted that the abducted 
leg seems longer. (See Fig. 159.) 



Right angle flexion in hip disease partly- 
concealed by the compensatory lordosis, and 
by the flexion at the knee and ankle. 



as it were, from the active attitude, making it a prop and adjunct 
of its fellow instead of an active aid in the propulsion of the body. 
This attitude is not voluntarily assumed by the patient ; it is involun- 
tary and persistent. It is sometimes called the stage of apparent length- 
ening. The leg seems longer than its fellow because it is held away 
from the axis of the body, and in order to bring it into the middle line 



230 TUBERCULOUS DISEASE OF THE HIP JOINT. 

and parallel to its fellow, the pelvis must be tilted downward on the 
diseased side, and upward on the other. The sound leg is drawn upward 
and the affected leg is lowered to a degree corresponding to the amount 
of abduction. (Fig. 160.) If, however, the anterior superior spines of 
the pelvis be placed upon the same plane, the distortion becomes evi- 
dent. (Fig. 159.) Thus the deformity of the limb is concealed or 
compensated by a tilting of the pelvis which twists the lumbar spine 
into a lateral convexity, toward the lower side. 

In the same manner the persistent flexion of the leg is concealed by 
a tilting of the pelvis forward, and by an increased hollowness or 
lordosis of the lumbar region. (Fig. 161.) Normally, in childhood at 
least, the lumbar spine and the popliteal surface of the knee should touch 
the table when the patient lies upon his back, but if the leg is fixed in 
flexion, the lumbar region must be arched and raised from the table 
when the leg rests upon it. Thus, in order to make the flexion appar- 

Fig. 162. 













Y 












! 




|^-~ ^^^^W| 




^X^^ 


J 








E9EL- *^~- 








H'JH 













The degree of fixed flexion is shown when the lumbar spine is held in contact with the table by 

flexing the other thigh. 

ent, the lumbar spine must be forced to touch the table, and this is 
possible only when the leg is raised to a degree corresponding to the 
deformity. (Fig. 162.) If the spine were rigid, as in advanced cases 
of rheumatoid arthritis, this compensation would be impossible, and if 
the patient were placed upon his back the leg could not be brought 
down to the table ; or if both limbs were distorted, as is sometimes 
the case when both hip joints are diseased, the limbs would be widely 
separated or crossed over one another, according as the deformity were 
in abduction or adduction. 

Flexion, Adduction and Inward Rotation — The Stage of 
Apparent Shortening. — If the disease is of a more acute type, 
and if locomotion be permitted, the attitude usually changes to one 
of increased flexion, and adduction and inward rotation replace ab- 
duction and outward rotation. This attitude is an indication that the 
part is so disabled as to be of little use, and it is instinctively drawn 



SYMPTOMS. 



231 



into a more protected attitude where it may be used as little as pos- 
sible. If the patient be confined to the bed, or does not walk, as in 
hip disease in infancy, the attitude of abduction may persist, although 
the muscular spasm may be intense. Thus it would appear that 
locomotion has a distinct influence on the character of the distortion. 



Fig. 163. 



Fig. 164. 





The stage of apparent shortening. The adduc- 
tion of the right thigh is made evident by the in- 
voluntary crossing of the legs when the anterior 
superior spines are on the same plane. 



The stage of apparent shortening. When 
the adducted linib is placed in the line of the 
body, the pelvis is tilted upward to a corres- 
ponding degree on the adducted side and down- 
ward on the other. 

The patient has compensated for the appar- 
ent shortening by flexing the knee on the sound 
side. This does not appear in the photograph. 



Flexion, adduction and inward rotation cause apparent or practical 
shortening ; for in order to bring the adducted limb to the middle line 
of the body and parallel with its fellow, the pelvis must be tilted up- 
ward on the affected side and downward on the other, the lumbar 
spine bending with a convexity toward the lower side. (Figs. 164, 



232 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



Fig. 165. 



167.) If the level of the pelvis be restored, the adducted limb will be 
crossed over its fellow, and the deformity is made evident. (Fig. 163.) 
As has been stated the attitude of flexion, adduction and inward 
rotation, if it appears early in the disease, is usually an indication of 
acute and disabling pain and of corresponding intensity of muscular 
spasm. But in most instances it is associated with the later and de- 
structive stage of the disease and it by no 
means indicates that the preceding symptoms 
have been more than ordinarily acute. In fact 
it is the attitude characteristic of a so-called 
" natural cure " (Fig. 165) when mechanical 
treatment has not been employed. It more 
often accompanies the later stage of the dis- 
ease, because its causes are in great degree 
mechanical. 

The mechanics of the distortion will be 
made clearer if it be compared to the defor- 
mity symptomatic of dorsal dislocation of the 
hip. In this displacement the femur, forced 
upward and backward upon the pelvis, is fixed 
in an attitude of extreme flexion, adduction 
and inward rotation. Each of the destructive 
changes of hip disease, the enlargement of 
the acetabulum, the depression of the neck 
of the femur, the erosion of the head of the 
bone, allows an elevation of the femur upon 
the pelvis or an approximation to a dorsal dis- 
placement. (Fig. 169.) If this displacement 
occur suddenly, as in certain cases of acute 
disease attended by effusion and rupture of 
the capsule, the limb immediately assumes an 
attitude typical of dorsal dislocation ; but in 
the ordinary form of disease the changes are 
very gradual, the pelvis and the femur, being 
in most instances undeveloped, more easily 
accommodate themselves to the changed con- 
ditions so that the actual distortion is less 
marked than in a similar subluxation of 
traumatic origin in the adult, but the simile 
will serve to illustrate the mechanical causes 
of distortion, and why such deformity may 
recur after correction, even though the disease has entirely disappeared. 
Outward rotation of the limb is usually associated with abduction, 
and inward rotation with adduction, but in certain instances outward 
rotation may be combined with adduction and vice versa. These ir- 
regular attitudes are more often observed in cases that have received 
mechanical or operative treatment. 

As has been stated, the distortions of the early stage of hip disease 




The final effect of hip disease 
when untreated. The natural 
cure, with flexion and adduc- 
tion. 



SYMPTOMS. 



233 



are caused almost entirely by muscular contraction which relaxes^ under 
the influence of an anaesthetic, but after a time the attitude is still 
further assured by accommodative changes in the muscles and fasciae, 
and by contractions and adhesions about the capsule. Thus an attitude 
which was originally a symptom may persist after the cure of the disease. 



Fig. 166. 



Fig. 16' 





Untreated hip disease. Flexion de- 
formity to nearly a right angle with 
the body. Trochanter two inches 
above Nelaton's line. Compensatory 
lordosis. 



Stage of apparent shortening. The left limb is 
adducted 35°, making an apparent shortening mea- 
sured from the umbilicus of more than two inches. 
In order to reduce the obliquity of tbe pelvis, the 
adducted leg must be crossed over its fellow. (See 
Fig. 163.) The apparent shortening is compensated 
by the flexion at the knee on the sound side. This 
is not made clear in the photograph. 



In conclusion it may be stated that flexion is practically an invari- 
able symptom in hip disease because complete extension, the attitude 
that puts most strain upon the joint, is first restricted. Flexion is, in 
the milder or in the earlier class of cases, usually combined with ab- 



duction and outward rotation, the attitude of inactivity. Increased 



234 TUBERCULOUS DISEASE OF THE HIP JOINT. 

flexion, accompanied by adduction and inward rotation in the early 
stage, is an indication of a more acute phase of the disease, but if the 
attitude is retained for a time it becomes fixed by accommodative 
changes in the tissues so that this distortion is not unusual in cases in 
which the damage to the joint may be very slight, as for example, 
when it follows rheumatism or some form of infectious arthritis. But in 
most instances the attitude is indicative of more advanced disease and 
of serious changes within the joint. 

Changes in the Contour of the Hip. — In the early stage of the 
disease the changes in contour are caused in great part by the attitude 
of the limb. If, as is usual, it is flexed, abducted and rotated outward, 
the buttock appears somewhat flatter and broader than its fellow. The 
gluteo- femoral fold is lower because of the tilting downward of the 
pelvis and it is shallower because of the flexion. If the thigh is ad- 
ducted, the gluteal fold will be elevated and shortened. On the 
anterior aspect, the inguino-femoral fold is deepened and lengthened 
by flexion and adduction, while abduction makes it less noticeable. 
Hoffman has called attention to the fact that the genitals and the inter- 
gluteal fold point toward the adducted and away from the abducted 
thigh. Adduction makes the trochanter more prominent, and abduc- 
tion makes it less prominent. 

To these primary changes in the appearances must be added the 
effect of atrophy or of infiltration and swelling, due directly to the dis- 
ease. A certain amount of swelling is often apparent in the inguino- 
femoral region, and infiltration of the deeper tissues is sometimes 
evident on palpation. In such cases there is usually a certain sensitive- 
ness to deep pressure, behind or in front of the trochanter. Palpable 
or evident abscess is unusual in the early stage of the disease. 

Atrophy. — Atrophy is an important sign of joint disease. It is 
often appreciable to the eye and to the hand, and it is always demon- 
strable by measurement. It is an important symptom because, if well 
marked, it shows that the disease must have existed for some time, 
whatever may be the statement of the patient's relatives. 

The atrophy affects the muscles of the entire limb, although it is 
somewhat more marked in the muscles of the thigh than in the calf. 
In the ordinary case of hip disease in childhood, when the patient is 
first brought for treatment, it averages from one half to one inch in 
the thigh and somewhat less in the calf. 

The Causes of Atrophy.— The causes of the atrophy secondary 
to joint disease have been the subject of much discussion. As it is 
associated with an increase of the reflex excitability of the muscles, 
and as it often progresses with great rapidity, the prevailing theory has 
been that of Vulpian and Charcot, that it is of nervous or reflex origin. 
According to this hypothesis the atrophy is the result of a change in 
the trophic centers of the spinal cord, " an inertia/' due to irritation of 
the articular filaments of the nerves. 

Another theory has been advanced by Saborin. As branches of the 
same nerves are distributed to the joint and to the surrounding mus- 



SYMPTOMS. 235 

cles, he suggests that the atrophy may be caused by a direct implica- 
tion of the nerves whose filaments are involved in the disease of the 
joint, a form of molecular neuritis. 

Admitting that the secondary causes of atrophy are somewhat 
obscure, one cause, and by far the most important, is very evident. 
This is physiological disuse, and thus diminished nutrition of the 
limb which has become incompetent to carry out its full function. 
Atrophy is a constant symptom of simple disuse in the absence of dis- 
ease. If a bone has been broken, atrophy of the surrounding muscles 
is observed. If anchylosis of a joint occur from any cause, whether 
it be from injury or disease, atrophy of the muscles, whose function 
has been abolished, follows. Even the atrophy caused by disease of 
the hip joint is greater when the limb has been fixed in apparatus, 
than when none has been applied, although the treatment has allayed 
the pain and has checked the progress of the disease. This point is 
illustrated by the observations of Brackett l who contrasted the atrophy 
of hip disease in two groups of patients, in one of which motion had 
been permitted, while in the other fixation, as complete as possible, 
had been employed. In the first group the average of atrophy was but 
1 per cent, of the volume of the thigh and .89 per cent, of that of the 
leg, as contrasted with 23 per cent, and 17 per cent, in the second 
class. 

It has been stated in objection to this theory that atrophy is observed 
even though the patient be confined to the bed, but under these 
conditions there would be relative disuse of a limb if motion caused 
pain or discomfort. Meanwhile a lesser atrophy might be demonstrated 
in the sound limb that had been deprived of its normal stimulus, just 
as relative hypertrophy of a limb which has to perform double func- 
tion, is often observed. 

The atrophy caused by physiological disuse and diminished nutrition 
affects all the components of the limb. The skin becomes thinner, the 
muscles lose in volume, the contractile substance is replaced in part by 
fat and by fibrous tissue, and the medullary canals of the bones enlarge 
at the expense of the cortical substance. 

In childhood, the period of rapid development, disuse often causes 
a retardation in growth of the entire extremity. This may be apparent 
in the foot when it is placed by the side of its fellow, while the dimin- 
ished growth in length of the limb, may be demonstrated by measure- 
ment. Brackett, in a series of cases, found this shortening to be dis- 
tributed as follows : average loss of the femur, 6.6 per cent, and of 
the tibia 5.4 per cent, of the normal length. 

This atrophy, the direct result of the disease and of the long con- 
tinued disuse during the period of repair, becomes less noticeable after 
function is resumed. The degree of final inequality depending upon 
the severity of the disease, the duration of the treatment and upon the 
impairment of function. But even when free motion in the joint is 
retained, a certain amount of atrophy always persists and the loss in 
1 Trans. Am. Orth. Ass'n, Vol. IV. 



236 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



growth is never replaced. If motion is completely abolished the muscles 
about the joint lose in bulk in proportion to the disuse of their normal 
function ; whereas the bones of the limb which are still used to sup- 
port the weight retain to a greater degree their normal size and length. 
Combined with the atrophy of the weak limb there is a relative hyper- 
trophy of the sound leg which is forced to assume more than its share 
of work. 

Actual Shortening. — Actual shortening of the limb is a common 

Fig. 168. 




Early stage of disease of the left hip joint (to the right in the picture) of the synovial type, show- 
ing irregularity in the shape of the acetabulum. 



effect of hip disease, but it can hardly be called a symptom for it is not 
present in the early stage of the disease. 

The causes of actual shortening may be classified as : 

1. Disuse of the limb. 

2. The effect of the disease upon the epiphysis of the head of the femur. 



SYMPTOMS. 



237 



3. The more general destructive effects of the disease that cause up- 
ward displacement of the femur, 
(a) Erosion of the head. 
(6) Erosion of the acetabulum, 
(c) Depression of the neck of the femur. 
Disuse, throughout a long period of treatment, may cause a certain 
amount of shortening of the entire limb. To this the shortening of the 

Fig. 169. 




Advanced disease showing wandering of the acetabulum and the obliquity of the pelvis due to ad- 
duction. Actual shortening 1 inch, apparent shortening 3 inches. 

bones of the leg and of the foot may be attributed in great part. If 
the epiphysis of the head of the femur is destroyed in whole or in part 
or if the disease hastens its union with the bone, a certain loss of growth 
must follow. This is of course slight in degree because this epiphysis 
is relatively unimportant compared with that at the lower extremity of 
the bone. From these two causes, the atrophy of disuse and the effect 
of the disease upon the epiphysis, relative shortening of the limb may 
increase after the disease is cured. 



238 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



Erosion of the head of the femur and of the upper border of theacetab- 
ulum are usually combined in those cases in which the shortening is in 
part dependent on upward displacement of the trochanter. (Fig. 156.) 
Depression of the neck of the femur to an appreciable degree is less 
common. Elevation of the trochanter, due to one or more of these 
causes, a form of subluxation, is very common, particularly so in those 
cases in which the protective treatment has been inefficient. Greater 
displacement follows fracture of the weakened neck and complete ab- 
sorption of the head, and occasionally a fairly normal femur may be 
actually dislocated as a result of sudden eifusion into the joint with 
rupture of the capsule, a form of pathological dislocation. 

Actual Lengthening of the limb as the result of disease is occa- 
sionally observed, caused it may be inferred, by stimulation of the 
growth of the epiphysis of the head ; but the most extreme instances 
are those in which the upper portion of the shaft of the femur is in- 
volved, the lengthening being the effect of an irritative hypertrophy. 

Retardation of Growth. — As has been stated, all the components 
of the limb are affected by the retardation of the growth. Brackett's 
observations on this point have been mentioned, and the following table, 
showing the relative measures of the bones in cases under treatment 
by Bollinger 1 of Budapesth, presents the subject in a convenient form : 



No. 
of case. 


Age at inception. 


Duration 
of disease. 


Length 
of femur in cm. 


Diffe- 


Length 
in tibia in cm. 


Diffe- 


Years. 


Months. 


Years. 


Months. 


Diseased. 


Normal. 




Diseased.! Normal. 


rence- 


1 


8 


6 


— 


6 


28£ 


28 


+h 


24 


24 





2 


3 


4 


— 


8 


23 


24 


1 


19 


19 


— 


3 


2 


10 


1 


8 


24 


24 


— 


19.5 


19.5 


— 


4 


5 


— 


2 


— 


29 


30 


1 


23.5 


23.5 


— 


5 


6 


— 


2 


— 


27 


28 


1 


23 


23 


— 


6 


7 


— 


2 


— 


32 


33 


1 


27 


27 


— 


7 


9 


— 


2 


— 


37 


37 


— 


30 


30 


— 


8 


1 


— 


4 


— 


22 


24 


2 


18.5 


19 


0.5 


9 


13 


— 


4 


— 


38 


41 


3 


34 


34 


— 


10 


4 


6 


5 


— 


32 


34 


2 


27 


27 


— 


11 


— 


2J 


6 


— 


26 


27 


1 


a* 


23 


1 


12 


13 




7 


— 


38 


40 


2 


33 


33 


— 


13 


2 


— 


8 


— 


35 


36 


1 


28 


28 


— 


14 


6 


— 


8 


— 


38 


38 


— 


31 


32 


— 


15 


11 


— 


8 


— 


40 


44 


4 


34 


34 


— 


16 


5 


— 


10 


— 


45 


46 


1 


— . 


— 


— 


17 


5 


— 


11 


— 


41 


44 


3 


31 


37 


6 


18 


6 


— 


14 


— 


44 


48 


4 


36 


39.5 


3.5 


19 


2 


— 


18 


• — 


36 


46 


10 


38 


38 


— 


20 


2 


— 


28 


— 


44J 


45 


i 

2" 


37.5 


37.5 


— 



A similar investigation of thirty-three cases under treatment at the 
Hospital for Ruptured and Crippled, New York, has been made re- 
cently by Dr. Henry Ling Taylor. In these cases the shortening of 
the bones was found to be more generally distributed than in those re- 
ported by Dollinger, as is illustrated by the following table : 

1 Zeits. fur Orth. Chir., Bd. 1, 1892. 



SYMPTOMS. 



239 











Dura- 


Dura- 






Shortening in inches. 






Sex. 


Age. 


Side. 


tion of 
disease, 
years. 


tion of 

treatm., 

years. 


Ab- 
scess. 










Case. 


Entire 
limb. 


Femur. Tibia. 


Foot. 


Patella. 


1 F. 


U 


L. 


1 




No 


} 


- ! * 


t 


* 


2 


M. 


7 


E. 


1* 




No 


i 


i 


* 


£ 


3 


M. 


5 


L. 


2 




No 


* 


4 4 


* 


* 


4 


M. 


5 


E. 


2 


H 


No 


* 


i I 


3. 
8 


i 


5 


M. 


6£ 


L. 


n 


1 1 


Yes 


f 


1 t 


t 


* 


6 


F. 


U 


L. 


3 


3 


No 


— 







i 


7 


F. 


6£ 


E. 


3 


— 


No 


J 





i 







8 


M. 


6 


E. 


3 


2h 


No 


H 


i 


i 


h 


* 


9 


F. 


13 


L. 


3* 


2 


No 


3 

4 




t 


} 


* 


10 


F. 


7 


L. 


3* 


3^ 


No 


If 


* 


3 

4 


i 


i 


11 


M. 


7 


E. 


3* 


3£ 


Yes 


1 


* 


* 


3 

4 


# 


12 


F. 


11 


E. 


3* 


1* 


No 


If 


i 


5 

8 


4 L 


A 


13 


F. 


9 


L. 


3* 


3* 


No 


u 


— J 


1 
2 


i 


Av 


erage 


7 




2* 


2 




3 
4 


* 


* 


1 

4 


* 



14 


M. 


7 


R. 


4 


4 


No 


1 


a 


4- 


3 


1 
2" 


15 


F. 


8* 


E. 


4 


4 


No 


1 


* 


* 


1 
4 


1s 


16 


F. 


12 


E. 


5 


4 


Yes 


3^ 


* 


H 


1 


X 


17 


F. 


11 


E. 


5£ 


4 


Yes 


24- 


1 


* 


* 


* 


18 


F. 


13 


L. 


6 


3 


No 


2 


i 


1* 


* 


* 


19 


F. 


12 


L. 


6 


4 


No 


7 
"g" 


4 


3_ 
4 


* 


1 


20 


F. 


10 


L. 


6* 


4 


No 


U 


* 


4- 




i 


21 


M. 


14 


L. 


7 


X 


Yes 


2* 


X 


t 


3_ 

4 


i 


22 


F. 


15 


E. 


7 


5 


No 


21- 


X 


1 


* 


X 


23 


M. 


9.} 


E. 


7 


* 


Yes 


n 


— 


* 


1 


X 


Average 


11 




5£ 


3£ 




it 


1 


t 


J 


3 

8 



24 


F. 


13 


E. 


8 


7 


Yes 


2^ 


* 


H 


1 


\ 


25 


M. 


15 


E. 


9 


6 


Yes 


4* 


2 


If 


X 


X 


26 


M. 


10J 


E. 


9 


X 


No 


n 


* 


* 


1 


f 


27 


F. 


18 


E. 


9 


/ 


No 


2| 


X 


1 


* 


1 


28 


M. 


18 


R. 


11 


10 


Yes 


2 


* 


1 


4 


X 


29 


F. 


15 


L. 


11 


7 


Yes 


3 


i 


i 


I 


f 


30 


F. 


15 


E. 


11 


5 


Yes 


1 


* 


* 


* 


\ 


31 


F. 


15 


E. 


11* 


U 


Yes 


3 


t 


f 


h . 


\ 


32 


F. 


16 


L. 


14 


1 


No 


H 


3. 


f 


* 


\ 


33 


F. 


21 


L. 


17 


6 


Yes 


H 


2J 


2£ 


f 


\ 


Average 


15 




11 


6 




2| 


1 


1 


\ 


f 



— Measurements equal. 

x Measurements not taken. 

Measurements of the femur from the apex of the great trochanter to the knee joint. 
Patella measured transversely. The cases are grouped according to the duration of 
disease and the averages are given separately for each group. 



Dr. Taylor measured also ten cases of unilateral poliomyelitis, in 
patients of an average age of thirteen years with an average duration 
of disability of ten years. The average shortening in these cases was 
one and three-fourths inches and in no case was it greater than two 
and one-half inches. It will be noted that the retardation of growth 
in this group corresponds closely with that of the third group of cases 
of hip disease, in which the disability was of about the same duration. 



240 TUBERCULOUS DISEASE OF THE HIP JOINT. 

Taylor concludes that the retardation of growth from unilateral hip 
disease in childhood is dependent in great degree upon the duration 
of the disability and upon the corresponding restraint of function. 
Similar observations on fifty cases of hip disease have been recorded by 
Hibbs. 1 In eleven of these cases the femur was found to be slightly 
longer on the diseased side. 

General Symptoms of the Disease. Debility. — If the disease be 
sufficiently painful to cause loss of sleep, and to affect the appetite, 
pallor and loss of flesh and strength may be expected. It must be 
borne in mind, however, that the patient may have been " delicate " 
long before the local tuberculous disease was acquired. At. all events, 
from the diagnostic standpoint at least, the local disease has no charac- 
teristic influence upon the general condition and the appearance of per- 
fect health is not at all unusual among patients with hip disease. 

Fever. — It is probable that a slight elevation of temperature might 
be detected in a large proportion of the patients, and in such cases 
actual appreciable fever often follows over-exertion or injury. Fever, 
as a symptom of infected abscess in the later stage of the disease, is of 
course of importance, but in the early stages of the disease the record 
of the temperature would be of but little diagnostic value. 

The History and the Method of Examination. — In considering 
the differential diagnosis of tuberculous disease of the hip joint one 
should keep its characteristics in mind. It is a chronic disease, in 
that the symptoms may have been present for weeks or months or 
even years before the patient is brought for treatment. It is a disease 
confined to a single joint, thus differing from rheumatism and similar 
affections in which several joints are involved. It does not get well ; 
thus it may be differentiated from injury and from the minor affections 
that simulate some of its symptoms. It causes a limp. It is accom- 
panied by reflex muscular spasm, usually by a certain amount of de- 
formity and by general atrophy of the muscles of the limb. 

The importance of the inheritance and of the personal history of the 
patient has already been mentioned in the consideration of Pott's dis- 
ease. In recording the history in this, as in all other chronic diseases 
of childhood, one attempts to ascertain the approximate duration of 
the pathological process rather than the duration of the more acute 
symptoms for which the patient has been brought for treatment. One 
asks, therefore, when the child was last perfectly well, and, bearing in 
mind the remission of symptoms, one asks if limp or pain had been 
noticed at any time before the more acute symptoms. In the history 
there is almost invariably mention of a fall, and one must ascertain 
whether the fall had any influence in the causation of the symptoms, 
remembering that the weakness and interference with function due to 
joint disease more often cause falls than falls cause joint disease. 

Physical Examination. — One begins the physical examination by 
the observation of the general condition of the patient and notes the 
attitudes and the character of the limp. The patient's clothing is then 
iN. Y. Med. Jour., Dec. 16, 1899. 



PHYSICAL EXAMINATION. 241 

entirely removed and one may observe the contour of the part and the 
general influence of the aifection upon the mechanism of the body. 
The patient is then placed on his back upon a table, with the legs 
parallel to one another, so that their relative length and size may 
be observed. If the pelvis is level, when the limbs are parallel, 
there can be no persistent abduction or adduction, for when the two 
anterior superior spines are on the same plane, such distortion is al- 
ways evident. If the lumbar spine and the popliteal surfaces of the 
knees rest on the table simultaneously, it shows too that persistent flex- 
ion is absent. One next tests the functions of the hip joints, always 
beginning with the sound side for the purpose of comparison and in 
order that the patient may become accustomed to the manipulation, be- 
fore the one suspected of disease is tested. Muscular spasm, due to 
disease within a joint, limits motion in every direction, thus differing 
from various conditions outside the joint that may limit its motion in 
one or more, but not in all directions. 

One compares the flexion, abduction, adduction and rotation of the 
limbs while the child lies upon its back ; it is then turned upon its 
face to test for extension, by holding the pelvis flat upon the table with 
one hand, while the thigh is gently elevated with the other. (Fig. 16.) 
The normal range of extension, in childhood, is at least ten degrees 
backward from the line of the body, and limitation of this range is the 
earliest sign of approaching deformity of hip disease. It may precede 
the restriction of the extremes of motion in other directions, although 
this is unusual, and if this motion is unrestricted, disease of the joint 
may be, practically speaking, excluded. The character of the reflex 
spasm that limits motion, and the indications of discomfort when the 
limit has been reached have been described. 

Measurements. — The measurements of the limbs are then made. One 
first ascertains the actual length of the limbs by measuring from the 
anterior superior spines of the pelvis to the extremities of the internal 
malleoli, actual shortening being of course absent in the early sjage of 
the disease. The second measurement is from the umbilicus to show 
the amount of apparent shortening or lengthening that may be present 
if the limb is distorted. The actual length of the legs, as measured 
from the anterior superior spines, is not changed by tilting of the pel- 
vis, but as the umbilicus is in the middle line of the body above the 
pelvis, measurement from this point simply shows the actual distance 
to the malleoli. Adduction causes an obliquity of the pelvis, conse- 
quently the malleolus on the affected side is drawn upward or nearer 
to the umbilicus, while the other is carried downward to a correspond- 
ing distance. (Fig. 167.) If, then, the measurements from the um- 
bilicus to the malleoli do not correspond relatively with those from the 
anterior superior spines, when the limbs are parallel and in the median 
line, it shows distortion ; adduction, if the limb is relatively shorter, ab- 
duction, if it is relatively longer than is shown by the measurement 
from the anterior superior spine. It has been stated that the measure- 
ment from the anterior superior spine is not changed by ^distortion. 
16 " '" 



\ 



242 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



It is, however, shortened slightly by outward rotation and more appre- 
ciably by abduction and also by flexion. Flexion on one side causes a 
tilting forward of the pelvis that affects the measurements on both sides, 
thus it is customary, if the flexion is considerable, to raise the sound 
leg to the line of its fellow in making the comparative measurements, 
stating in the record that the limbs have been measured at the angle 
of the deformity. 

Method of Estimating the Degree of Distortion of the 
Limb. — As has been stated, when the pelvis is level, distortion of the 
limb is apparent, and the degree of distortion can be measured by the 
goniometer. (Fig. 159.) But it may be more easily ascertained by 
" Lovett's table." 1 This method is described by its author as follows : 



Table I. 
Distance Between Anterior Superior Spines in Inches. 





4- 
\ 

3. 
4 

1 

n 
if 

2 

2| 

3 

3i 

3J 

3| 

4 


3 


3J 


4 


4* 


5 


H 


6 


6* 


7 


n 


8 


H 


9 


9* 


10 


11 


12 13 


"a 


5° 


4° 


4° 


3° 


3° 


2° 


2° 


2° 


2° 


2° 


2° 


2° 


2° 


1° 


1° 


1° 


1° 1° 


u 
o 


10 


8 


7 


6 


5 


5 


4 


4 


4 


4 


4 


4 


4 


3 


3 


3 


3 2 


-G 


14 


12 


11 


10 


8 


8 


7 


7 


6 


6 


5 


5 


5 


4 


4 


4 


3 3 


G 


19 


17 


14 


13 


11 


10 


9 


9 


8 


7 


7 


7 


6 


6 


6 


5 


5 4 




25 


21 


18 


16 


14 


13 


12 


11 


10 


9 


9 


8 


8 


7 


7 


7 


6 6 


id 


30 


25 


22 


19 


17 


15 


14 


13 


12 


12 


11 


10 


10 


9 


9 


8 


7 7 


e« 


36 


30 


26 


23 


20 


18 


17 


15 


14 


13 


13 


12 


11 


10 


10 


9 


8 8 




42 


35 


30 


26 


23 


21 


19 


18 


16 


15 


14 


14 


13 


.12 


12 


10 


10 9 


G 
05 




40 


34 


30 


26 


24 


21 


20 


19 


17 


16 


15 


14 


14 


13 


12 


11 10 


03 






39 


34 


29 


27 


24 


22 


21 


19 


18 


17 


16 


15 


14 


13 


12 11 


CO 








38 


32 


29 


27 


25 


23 


21 


20 


19 


18 


17 


16 


14 


13 12 


.5 








42 


35 


32 


29 


27 


25 


23 


22 


21 


19 


18 


18 


16 


14 13 












39 


36 


32 


30 


27 


26 


25 


22 


21 


20 


19 


17 


15 14 


G 
0) 












40 


35 


33 


30 


28 


26 


24 


23 


22 


21 


19 


17 16 


S' 








... 






38 


35 


32 


30 


28 


26 


25 


23 


22 


20 


18 17 














42 


38 


35 


32 


30 


28 


26 


25 


23 


21 


19 18 



" To measure by this method, the patient is made to lie straight, with 
the legs parallel. Real shortening is measured with the ordinary tape 
measure, and apparent shortening is obtained in the same way. It 
may be repeated that real or bony shortening is measured from the 
anterior superior iliac spines to each malleolus, and that practical 
shortening is found by a measurement taken from the umbilicus to 
each malleolus. The difference in inches between the two kinds of 
shortening is seen at a glance. The only additional measurement 
IE, W. Lovett, Boston Med. and Surg. Jour., March 8, 1888. 



METHOD OF ESTIMATING THE DEGREE OF DISTORTION. 243 

necessary is the distance between the anterior superior spines, which is 
taken with the tape. Turning now to the table, if the line which 
represents the amount of difference in inches between the real and ap- 
parent shortening is followed until it intersects the line which repre- 
sents the pelvic breadth, the angle of deformity will be found in 
degrees, where they meet. If the practical shortening is greater than 
the real shortening, the diseased leg is adducted ; if less than real short- 
ening, it is abducted. Take an example : Length (from anterior superior 
spine) of right leg, 23 ; left leg, 22J ; length (from umbilicus) of right 
leg, 25 ; left leg, 23 ; real shortening, J inch, apparent shortening 
2 inches; difference between real and practical shortening, 1J inches; 
pelvic measurement, 7 inches. If we folio w the line for 1J inches 
until it intersects the line for pelvic breadth of 7 inches, we find 12° 
to be the angular deformity, as the practical shortening is greater than 
the real, it is 12° of adduction of the left leg. If apparent lengthen- 
ing is present its amount should be added to the amount of actual 
shortening." 

If flexion be present the degree may be ascertained by raising the 
flexed leg until the lumbar spine touches the table, when the angle 
formed by the leg with the body may be measured with the goniometer 
(Fig. 162), or its degree may be ascertained by Kingsley's table. 

" The patient lies upon a table flat on his back and the surgeon flexes 
the diseased leg, raising it by the foot until the lumbar vertebrae touch 
the table, showing that the pelvis is in the correct position. The leg 
is then held for a minute at that angle, the knee being extended, while 
the surgeon measures off two feet on the outside of the leg with a tape 

Fig. 170. 




a c 

Kingsley's method of estimating flexion. 



measure, one end of which is held on the table (so that the tape mea- 
sure follows the line of the leg) (AB). From this point on the leg (B) 
where the two feet reaches by the tape measure one measures perpen- 
dicularly to the table (BC), and the number of inches in the line BC 
can be read as degrees of flexion of the thigh, by consulting Table II. 
For instance, if the distance between the point on the leg and the 
table is 12J inches it represents 31° of flexion deformity of the thigh. 



244 



TUBERCULOUS DISEASE OF THE HIP JOINT 



Table II. 1 



In. 


Deg. 


In. 


Deg. 


In. 


Deg. 


In. 


Deg. 


0.5 


1 


6.5 


16 


12.5 


31 


18.5 


50 


1.0 


2 


7.0 


17 


13.0 


33 


19.0 


52 


1.5 


3 


7.5 


19 


13.5 


34 


19.5 


54 


2.0 


4 


8.0 


20 


14.0 


36 


20.0 


56 


2.5 


6 


8.5 


21 


14.5 


37 


20.5 


58 


3.0 


7 


9.0 


22 


15.0 


39 


21.0 


60 


3.5 


9 


9.5 


24 


15.5 


40 


21.5 


63 


4.0 


10 


10.0 


25 


16.0 


42 


22.0 


67 


4.5 


11 


10.5 


27 


16.5 


43 


22.5 


70 


5.0 


12 


11.0 


28 


17.0 


45 


23.0 


75 


5.5 


14 


11.5 


29 


17.5 


47 


23.5 


80 


6.0 


15 


12.0 


30 


18.0 


48 


24.0 


90 



" If the leg is so short that it is impracticable to measure off twenty- 
four inches, one can measure twelve inches ; ascertain from here the 
distance to the surface on which the patient is lying in a perpendicular 
line in the same way, then doubling this distance and looking in the 
table as before the amount of flexion is found." 

Atrophy. — The circumference of the thighs, the knees and the calves 
is then measured at corresponding points, to test for atrophy or for 
other irregularities that may require explanation. The atrophy of 
joint disease affects the entire limb, and is an unfailing symptom ex- 
cept in the earliest stage of the disease. It might be concealed in the 
thigh by a deep abscess, but it would still appear in the calf. 

Local Signs of Disease. — The hip joint is so concealed by the 
overlying tissues that the local sensitiveness and swelling which usu- 
ally accompany similar disease at the knee and ankle, are often absent. 
Firm pressure, before or behind the trochanter, or over the head of 
the femur, usually causes some discomfort, however. In many instances 
a peculiar resistance of the deeper parts, caused by infiltration of the 
tissues that cover the joint, is evident on palpation ; and swelling 
about the joint and thigh, caused by effusion or by deep abscess, is not 
unusual when patients are first brought for treatment. Sensitiveness 
of the skin, and local elevation of the temperature may be present if 
the disease is acute, particularly if an abscess is on the point of break- 
ing through the skin. 

It must be evident that the diagnosis of tuberculous disease of the 
hip, except perhaps in the stage of inception, is in most instances evi- 
dent on a systematic examination, such as has been outlined ; and it is 
probable that errors are due rather to a neglect of such examination 
than to any particular obscurity that the ordinary case may offer. 

Diagnosis. Local Irritation. — Strains of the muscles of the thigh, 
enlarged glands in the groin, irritation or disease of the genitals may, 
in infancy or early childhood, cause persistent flexion of the thigh and 
pain on motion. Simple muscular strains quickly recover, while the 
inflamed glands, and other causes of local irritation, are usually ap- 
parent on inspection. 

1 G. L. Kingsley : Bost. Med. and Surg. Jour., July 5, 1888. 



DIAGNOSIS. 245 

" Growing Pains." — So-called growing pain is probably due in many 
instances to strain of the muscles or to injury about the hip ; in other 
cases it may be explained by rheumatism. 

Local Injury. — It would appear that injury, often of a trivial char- 
acter, may cause congestion in the neighborhood of the epiphyseal car- 
tilage of the head of the femur and that injury of this character in 
delicate children may be the predisposing cause of tuberculous disease. 
Such a sensitive condition causes a limp, pain or discomfort on over- 
use and a certain amount of restriction of motion. These symptoms 
may last a few days or a few weeks ; they may disappear and recur 
from time to time and they can only be distinguished from those of 
incipient disease by continued observation. 

Synovitis. — In certain cases of injury synovial effusion may be pres- 
ent, although this is unusual. 

In the cases in which the functional disturbance is caused by local 
irritation or by slight strain the symptoms are of sudden onset and are 
evidently of trivial importance, but if there is any doubt as to the 
diagnosis, the hip should be bandaged and the patient should remain 
in bed or at rest, until the complete subsidence of the symptoms or 
their persistence, makes the diagnosis clear. 

Anterior Poliomyelitis. — Occasionally anterior poliomyelitis may be 
accompanied by pain on motion in the affected limb, before paralysis is 
apparent ; but in a few days, at most, the diagnosis is evident. 

Rheumatism. — Rheumatism is usually of sudden onset. It is al- 
most always migratory in character and it is accompanied by fever. If it 
were confined to a single joint, as is sometimes the case in young chil- 
dren, and if the history were obscure, the diagnosis might be uncer- 
tain for a time. In such cases appropriate remedies should, of course, 
be employed. 

Scurvy. — This is also an affection whose symptoms are general in 
character. It is, therefore, more likely to be confounded with rheu- 
matism than with a local disease. In rare instances one joint only ap- 
pears to be involved, but this is, as a rule, the knee rather than the 
hip. Pain on motion of the limbs, in an infant artificially fed, always 
suggests scurvy. 

Infectious Arthritis. — Mild forms of infectious arthritis may follow 
scarlet fever, diphtheria, pneumonia and, in a more severe and de- 
structive form of typhoid fever. As a rule however several joints are 
involved and although the affection might be mistaken for rheumatism 
it could hardly be confounded with local tuberculous disease. 

Acute Epiphysitis. — Infectious arthritis or epiphysitis of the hip joint 
is not uncommon in early infancy. It is of sudden onset, accompanied 
by high fever and by constitutional disturbance. These symptoms to- 
gether with the local heat and swelling, caused by the rapid formation 
of pus, show the character of the affection and indicate the necessity 
for prompt surgical intervention. 

Extra-articular Disease. — Disease in the neighborhood of the joint, 
as of the trochanter, or of the tuberosity of the ischium, may cause a 



246 TUBERCULOUS DISEASE OF THE HIP JOINT 

limp and pain, but in most instances the local sensitiveness and local 
swelling indicate the seat of the disease, while motion of the joint is 
limited only in the directions that cause tension on the sensitive parts. 

Chronic Rheumatoid Arthritis. Osteo-arthritis of the Hip. — Rheuma- 
toid arthritis, when confined to the hip joint, may be mistaken for 
tuberculous disease and at times the diagnosis may be obscure. This 
is, however, a disease cf adult life and it is in most instances accom- 
panied by other evidences of a general affection. 

Pott's Disease. — Disease of the lumbar region of the spine before the 
stage of deformity, when the pain is referred to the lower extremities, 
and in which unilateral psoas contraction causes a limp, is almost al- 
ways mistaken for hip disease although the distinction between them 
is very clear. Psoas contraction limits only extension ; all the other 
movements of the limb are free and unrestrained. The muscular 
spasm, of which the psoas contraction is a part, is a spasm of the 
muscles of the spine about the seat of disease, as is evident on exami- 
nation. Other causes of psoas contraction have been mentioned in the 
consideration of Pott's disease. In exceptional cases active disease of 
the lower region of the spine in young children may set up spasm of 
the muscles about the hip, and vice versa, so that it may be impossible 
to decide at the first examination whether the irritation is in the hip or 
in the spine or in both. 

Sacro-iliac Disease. — Disease of the sacro-iliac junction is very un- 
common in childhood. The symptoms and the attitude resemble 
sciatica rather than hip disease. There is local pain at the seat of dis- 
ease upon lateral pressure on the pelvis, and if the pelvis be fixed, the 
motion at the hip joint will be found to be free and painless. 

Disease of the Bursse about the Joint. — Inflammation of the bursa? 
about the hip may cause local swelling and sensitiveness, a limp and 
limitation of motion in certain directions, but the characteristic mus- 
cular spasm of hip disease is absent. Ilio-psoas bursitis forms a fluc- 
tuating swelling on the inner aspect of the thigh, gluteal bursitis, a 
localized swelling of the buttock. 

Coxa Vara. — Coxa vara, or depression of the neck of the femur, is a 
simple deformity in which disease is absent. It causes a limp and more 
or less discomfort, but the character of the deformity, shown by the actual 
shortening and by the elevation and prominence of the trochanter dis- 
tinguishes it from hip disease in which these are late symptoms. In 
coxa vara there is unequal limitation of motion, abduction, flexion and 
inward rotation being somewhat restricted while extension, the first 
motion limited in hip disease, may be even increased in range. 

Fracture of the Neck of the Femur in Childhood or Traumatic Coxa 
Vara. — Fracture of the neck of the femur in childhood is often of 
what may be termed the green-stick variety, a depression of the neck 
of the femur without actual separation of the fragments ; and in many 
instances the patients are able to walk about within a short time after 
the accident. In such cases the limp and discomfort, attended during 
the stage of repair by a certain degree of muscular spasm, are often 



THE RECORD. 247 

mistaken for the symptoms of disease. The history of the accident 
followed by immediate disability ; the shortening and the elevation of 
the trochanter, should establish the diagnosis. 

Congenital Dislocation of the Hip. — Congenital dislocation of the hip 
causes a limp, but it is a limp that has existed since the child began to 
walk and that is unaccompanied by the symptoms of disease. The 
nature of the disability should be apparent on examination. 

Hysterical Joint. — In hysterical subjects a limp, apparent pain and 
distortion of the limb, often following slight injury, may simulate disease. 

Hysteria is very uncommon at the period of life in which tubercu- 
lous disease is most frequent. Patients suffering from hysterical joints 
usually present other symptoms of hysteria; the characteristic signs of 
disease, muscular spasm and atrophy, are absent ; while the apparent 
discomfort and the voluntary distortion are quite out of proportion to 
the physical evidences of injury. 

The X-Ray in Diagnosis. — Roentgen pictures are of far more value 
in demonstrating deformity than in establishing early diagnosis of dis- 
ease, especially at the hip in early childhood, when so large a part of 
the extremity of the femur is cartilaginous. The pictures are of value, 
however, in showing the destructive effect of the disease on the head 
of the femur or acetabulum, and thus giving one a clearer conception 
of the actual condition of the joint than would be possible otherwise. 
(Fig. 1 68.) In older subjects it might be possible to demonstrate the 
presence of disease in the interior of the bone by this means, but in 
any event Roentgen pictures are of value only when interpreted by 
knowledge of the physical signs. 

Method of Recording a Case. — The record should contain the 
general history of the patient together with an account of the more im- 
portant symptoms, and of the treatment that may have been employed. 
The physical examination should include the weight and height, for 
comparison with the normal standard, and as a basis on which to judge 
the future progress of the case. Then follows a brief description of 
the gait and attitude ; of the character of the distortion, if it be pres- 
ent, and of the changes from the normal contour. If restriction of 
motion be present, its causes are stated if possible ; whether, for ex- 
ample, it is due to simple muscular spasm, or in part to adhesions and 
contractions. The presence or absence of heat and swelling, of ab- 
scesses, sinuses and the like, is indicated. If there is actual shorten- 
ing of the limb its causes and distribution should be stated ; whether 
it is the result of simple retardation of growth or of elevation of the 
trochanter, as may be ascertained by Nelaton's line and by Bryant's 
triangle. If the elevation is due in great part to the enlargement of 
the acetabulum, while the upper extremity of the femur remains fairly 
normal in shape, the projection of the trochanter is more noticeable, 
and the distortion of the limb in adduction is greater, than when the 
elevation is the result of destruction of the head of the bone. In this 
class of cases Roentgen pictures are of service in showing the actual 
condition of the joint. (Fig. 169.) 



248 TUBERCULOUS DISEASE OF THE HIP JOINT. 

A condensed account of the more important points in the physical 
examination may be presented by the formula used at the Hospital for 
Ruptured and Crippled, as follows : R.A.— R.U.— R.T.— R.K.— R.C. 
— A.G.E.— A.G.F.— A.S.P.— L.A.— L.U.— L.T.— L.K.— L.C. 

"A" indicates the distance from the anterior superior spines to the 
internal malleoli. 

" U," from the umbilicus to the same points. 

"T," "K" and "C," the circumferences of the limb at the thighs, 
knees and calves. 

"A.G.E." indicates the angle of greatest extension. 

"A.G.F.," the angle of greatest flexion. Thus the restriction of 
the range of antero-posterior motion at the hip is shown by these 
measurements. 

" A.S.P." is the transverse diameter of the pelvis between the ante- 
rior superior spines, the measurement required in Lovett's table for 
ascertaining the degree of lateral distortion. 

If, for example, the record read : 

R.A. 18£— R.U. 20 — R.T. 11 — R.K. 8|— R.C. 7f— A.G.E. 150— A.S.P. 7 
L.A. 18£— L.U. 21i— L.T. i i_ L.K. 8^— L.C. 1\— A.G.F. 90 

it would show at a glance that there was no real shortening, that the 
leg was abducted because there was one and a-quarter inches of apparent 
lengthening, according to the table, the equivalent of ten degrees of ab- 
duction. It would show that there was permanent flexion of thirty de- 
grees and a range of motion between the limits of flexion and extension 
of sixty degrees, as compared with the normal of about 1 30 degrees. 

The following details from the one thousand cases of hip disease in- 
vestigated for me by Dr. D. D. Ashley are of interest as illustrating 
the character of the cases treated at the Hospital for Ruptured and 
Crippled. 

The Duration of Disease when Treatment was Begun. 

Three months or less 396 Four years 21 

Three to six months 170 Five years 17 

Six months to one year 80 From five to ten years 35 

One year 124 From ten to forty year;- 16 

Two years 75 Not stated 37 

Three years 29 1~000 

The Degree of Deformity Present on First Examination. 
No deformity 130 55 degrees of flexion 10 



5 degrees of flexion 44 60 

10 " " " 89 65 

15 " " " 69 70 

20 " " " 118 75 

25 " " " 32 80 

30 " " " 135 85 

35 "■ " " 56 90 



26 

8 

22 

2 
11 

1 
12 



40 " " " 70 More than 90 1 

45 " " " 41 Not stated 55 



50 



1,000 



TREATMENT. 249 

Restriction of Motion at First Examination. 

Normal motion 30 

A range of motion through 105 degrees 14 

" " " 90 " 65 

" " " 75 " 49 

" " " 60 " 95 

" " " 45 " 67 

» " " 30 " 112 

" " " 15 " 95 

" " " 5 " 157 

No motion 147 

Not stated 169 

1,000 

Attitude of the Limb at First Examination. 

Flexion to a greater or less degree 814 

No flexion 130 

Not stated 56 

1,000 

Other Distortions Recorded. 

Abduction 254 

Adduction 167 

External rotation 166 

Internal rotation 58 

Actual Shortening when Treatment was Begun. 

i inch 129 

* " 143 

f " 22 

1 " 51 

1£ inches 9 

1* " 16 

If " 6 

2 " 21 

Shortening absent or not stated in 584. 
Abscess was present in 105 cases. 

Treatment. — The principles that should govern the treatment of a 
disease are best indicated by the study of cases that have received no 
treatment, and that show therefore the natural history of the affection. 

A characteristic case of tuberculous disease of the hip joint begins 
insidiously. It causes a slight limp and at times a certain amount of 
pain. In the early stage of the disease there is slight flexion of the 
limb, usually combined with abduction, the instinctive assumption of 
the attitude of rest. As the disease progresses, the limb becomes less 
capable of performing its proper function ; the range of painless motion 
becomes more and more restricted and the attitude changes to one of 
increased flexion and adduction, the attitude in which the limb is best 
protected from injury and in which it is least capable of performing its 
share of normal work. Pain is more constant, abscess is often present, 
and the constitutional effects of a depressing disease may be apparent. 



2\ inches 


5 


21 " 


5 


2f " 


2 


3 " 


2 


3i " 


2 


Ql U 


2 


9£ " 


1 




416 



250 TUBERCULOUS DISEASE OF THE HIP JOINT 

This progression of symptoms and attitudes is so fairly constant, that 
hip disease is often divided into stages corresponding to these early 
and later manifestations of its effects. When the limb has reached the 
position of greatest protection, when motion which at first was limited 
only by the involuntary spasm of the muscles that are now atrophied, 
is restricted by adhesions and contractions, pain often ceases to be a 
troublesome symptom, the general health improves and effective repair 
begins. During the progressive stage erosion of the opposing surfaces 
of the joint has advanced, always more rapidly at the points of mutual 
pressure and friction, the upper and inner surface of the head of the 
femur and the upper margin of the acetabulum, and here the disease 
remains active while repair progresses at the points which have been 
relieved from irritation. Thus, in many instances, the upper margin 
of the acetabulum is destroyed and a subluxation of the femur takes 
place (Fig. 155), a displacement favored by the attitude of flexion and 
adduction and induced by pressure upon the limb. In some instances 
there is complete displacement, and when the diseased parts are thus 
separated from one another by this form of pathological excision, relief 
of symptoms and practical recovery may quickly follow, although sin- 
uses leading to areas of local disease or to fragments of necrosed bone, 
may persist for many years. 

Nature's cure of hip disease implies recovery with a shortened and 
distorted limb, a final result which is common enough even when 
treatment has been employed to explain the popular conception of what 
hip disease entails. (Fig. 165.) 

There are many cases of hip disease in which the primary focus in 
the head of the bone is so limited in extent, that perfect functional 
cure may result under any form of treatment, or non-treatment even. 
And there are others in which the disease is of such a destructive 
character that the result must be disastrous in spite of treatment. But 
there can be no doubt that by early diagnosis and by efficient protec- 
tion, a vast amount of suffering may be prevented, that useful function 
may be preserved, which would otherwise have been lost. 

The object of treatment is to prevent the symptoms and the effects 
of the disease that have been outlined as characteristic of the untreated 
cases. To relieve the pain that depresses the vitality of the patient. 
To relieve the muscular spasm that induces distortion of the limb, and 
that stimulates the activity of the destructive process by increasing the 
pressure and friction of the diseased surfaces of the opposing bones. 
To correct and to prevent deformity and to prevent, as far as may be 
by lessening the pressure and by restraining motion, the upward dis- 
placement of the femur that causes irremediable distortion. 

There are cases in which radical removal of the diseased parts may 
be indicated and there are times when acute symptoms may require ab- 
solute rest of the patient. But it is evident in the management of a 
chronic tuberculous disease, throughout the period of years that may 
elapse before cure is accomplished, that the requirements of treatment 
which have been indicated must be met, as far as may be, by appli- 
ances that allow exercise in the open air. 



THE TRACTION HIP SPLINT. 251 

Mechanical Treatment. — The most effective treatment of a diseased 
joint is that which assures it the most perfect rest and protection. If 
the disease be in the earliest stage and confined to the interior of the 
bone, rest oifers the most favorable condition for repair and for pres- 
ervation of the joint. If the disease be further advanced, complete 
relief of function affords an opportunity for nature to check its prog- 
ress and to preserve, it may be, a part of a joint from invasion. If 
the joint be already involved, rest oifers the best opportunity for re- 
pair by preventing friction that stimulates the progress of the disease 
and increases its destructive effects. Whatever checks or retards the 
progress of the disease correspondingly relieves its symptoms and pre- 
vents the constitutional depression and thus preserves the vital resist- 
ance, both local and general, upon which the cure of the disease ulti- 
mately depends. 

Rest of a diseased joint of the lower extremity necessitates splinting, 
stilting and traction. 

Splinting naturally signifies the fixation that may be attained by 
the application of a splint, extending a sufficient distance on either 
side of the part to be fixed. 

Stilting — the elevation of the foot from the ground so that jar and 
pressure on the diseased articulation may be removed. 

Traction — a sufficient force exerted upon the limb to overcome and 
to control the spasmodic action of the muscles. 

The knee joint, the junction of two levers of similar size and func- 
tion may be easily controlled or placed at rest by means of apparatus. 
But the hip joint is a ball-and-socket joint which allows free motion 
in many directions, and being the junction of the body and the limb, 
two segments of different size and function, it is especially difficult to 
control. For this reason as much as any other, perhaps, the treatment 
of hip disease has been the subject of controversy for many years. 
And even at the present time one can hardly describe the treatment of 
hip disease adequately, without contrasting the methods of treatment 
that are in common use. 

Such an exposition should begin naturally with a description of 
what has long been known as the American treatment, in which trac- 
tion has always occupied the most important place. 

The Traction Hip Splint. — The traction hip splint consists of a pelvic 
band and an upright. The pelvic band is made of sheet steel about a 
quarter of an inch in thickness and one and one-eighth inches in width, 
sufficiently strong to support the weight of the body without yielding, 
bent into a U shape to conform to the pelvis, but wide enough to cause 
no antero-posterior pressure. As Taylor puts it, there should be room 
enough for the pelvis to move freely in it. This band embraces about 
three-quarters of the pelvis at a point just above the trochanters. It 
is covered with leather and is provided with a strap to complete the 
circumference. Upon the pelvic band four buckles are placed for the 
attachment of the perineal bands. The two buckles on the front band 
are placed directly above the attachments of the adductor muscles, on 



252 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



either side of the genitals. Behind, the buckles are placed much fur- 
ther apart, somewhat to the outer side of each ischial tuberosity, upon 
which, in great part, the weight of the body is to be supported. The 
pelvic band is bolted firmly to the upright at a slight inclination, cor- 
responding to the inclination of the pelvis. The upright extends from 
the top of the trochanter to two or more inches below the sole of the 
foot. It may be made in one piece or in two sections overlapped and 
attached to one another by screws, to allow for adjustment. (Fig. 172.) 
It is turned inward at a right angle below the foot and is shod with 
leather or rubber. The foot piece may be provided with a windlass 
(Fig. 171), or the traction may be made by simple straps attached 
on either side. At about the middle of the upright is placed a sup- 
port of light steel which is provided with a broad leather strap for the 
purpose of fixing the thigh to the brace and supporting the knee. In 
some braces a second similar support is placed at the upper part of the 
stem ; in others the knee is supported only by a broad leather pad 

which covers its inner surface and is attached to a 
Fig. 171. cross piece on the upright by straps, as in the Taylor 

brace. In the Taylor brace, which has served as a 



Fig. 172. 



Fig. 173. 





The traction hip splint with over-lapping upright and windlass, used at the Boston Children's Hos- 
pital. ( Bradford and Lovett. ) 



model for all similar appliances, the upright is a steel tube into which 
slides a rod, supporting the foot part of the brace, the two parts being 
joined with a rack-and-pinion attachment and lock, so that the brace 
may be lengthened or shortened by means of a key. (Fig. 178.) 



THE TRACTION BRACE. 



253 



Traction Straps. — Traction upon the limb is made by adhesive plas- 
ter, preferably that known as moleskin (yellow) plaster which is far 
less irritating to the skin than rubber plaster. 

These plasters should be cut into a shape corresponding to the lat- 
eral aspect of the thigh and leg, thus : wide above and narrow below, 
reaching from the trochanter on the outer, and from the pubes on the 
inner side, to the malleoli. (Fig. 195.) The lower ends are reinforced 
by a second layer of plaster and to them buckles are attached. The 
plasters are then applied to the limb and are held in place by a band- 
age which is smoothly applied and then sewed, 
Fig. 174. to prevent disarrangement. The object of the 

bandage is primarily to assure the adhesion of 
the plaster and secondarily to keep it clean. 
It can be replaced by a properly fitted covering 
of stockinette or by a stocking leg. 

Another method of ap- 
Fig. 175. plying the plaster, designed 

to attain a better hold upon 
the limb, is that devised by 
Taylor, and described by 
him as follows : " The first 
important object is to seize 
the leg in such a manner as 
to exert against it an un- 
yielding force. This should 
be done in such a manner 
as will not interfere with 
the circulation, nor injure 
the knee, by unequal strain 
either below or above it. In 
other words, the whole leg 
should be grasped in such 
a manner that the knee will 
be supported. It may be 
done as follows : A strip 
of adhesive plaster long 
enough to reach from the 
waist to the foot, and from 
three to five inches wide at 
the upper and about one-third that width at the lower end, is taken and 
cut into five tails as shown in accompanying illustration. (Fig. 174.) 
A piece from four to six inches long is cut from the center tail and 
added to the lower end to strengthen it ; and, if the patient be strong, one 
or two more pieces are laid on the same place, where a buckle is attached. 
Two similar straps are prepared, one for the inside and one for the outside 
of the leg, and laid against the lateral aspects of the leg, the ends with the 
buckles beginning about two inches above the internal and external 
malleoli, and the center tails reaching the entire length of the leg and 




C. F. Taylor's method of applying adhesive plaster. 



254 



TUBERCULOUS DISEASE OF THE HIP JOINT 



Fig. 17( 



thigh, to the perineum inside and the trochanter on the outside. The 
lower strips or tails are then wound spirally around the leg to the pelvis 
and afterward the other two pairs of tails, which are cut down to just 
above the knee, are also wound about the thigh in the same manner. 
When completed, the thigh is involved in a network of strips of adhesive 
plaster, which act equally and without pressure on the whole surface. 
The leg has about one-fourth of the attachments, and the thigh three- 
fourths, which is found to be the right proportion to protect the knee 
equally from compression or strain. A few turns of the roller band- 
age are then made around the ankle just under the lower ends of the 

straps, which serves as a protection to the 
flesh under the buckles, and then it is con- 
tinued over the straps on the whole leg. 
Thus prepared, the patient is ready for the 
splint. 7 ' 

At the Boston Children's Hospital the 
lower ends of the adhesive straps termi- 
nate in tapes that extend below the foot for 
attachment to the windlass, which is used 
with the cheaper form of brace. 

Perineal Bands. — Perineal bands are 
made by covering a firm, wide, unyielding 
band of webbing with several folds of 
blanket or similar material and then bind- 
ing it smoothly with canton flannel. These 
are made in different lengths and sizes, 
as may be required. 

The " High Shoe." — The best and light- 
est material for raising the shoe worn on 
the sound foot to correspond with the 
brace is cork, and the ordinary thickness 
is two and a-half inches. A good and 
cheap substitute may be made of light 
wood provided with a leather sole, and 
in certain cases a patten of metal may be 
used. 

The Application of the Traction Hip 
The traction hip brace. Original form. Splint. — The traction brace is applied in 

the following manner : 
The patient lying upon his back, the pelvic band is first adjusted 
and strapped about the body. The perineal supports are then drawn 
firmly into place so that pressure on the upright does not move the 
pelvic band from its proper position just above the trochanter. The 
brace is then pressed upward against the resistance of the perineal 
bands, while the leg is at the same time drawn downward and is fixed 
by attaching the straps to the buckles at the ends of the adhesive 
plasters. If the brace is provided with a windlass or ratchet, further 
traction is applied to the point of tolerance by means of the key, care 




THE TRACTION BRACE. 



255 



being taken in adjusting the brace that it does not project so far be- 
low the foot as to more than equal the extra length provided by the 
high shoe on the sound side. The knee band is then adjusted and in 
many instances a strap is placed about the ankle and the brace to as- 
sure greater security. The shoe is then put on, the leg clothing is 
drawn over the brace and the patient is allowed to stand. If in walk- 
ing the patient is inclined to tilt the foot downward and to bear the 




A 



The Judson brace. This has but one perineal band and the upright is bolted firmly to the pelvic band. 



weight on the toe, a heel strap is attached to the foot piece to hold the 
foot in the horizontal position. 

By means of this brace the weight is borne entirely upon the per- 
ineal bands, thus the joint is relieved from pressure and from jar. 
These perineal bands should be accurately adjusted to pass upward, in 
front, parallel to one another on either side of the genitals, in order to 
avoid pressure on the adductor region of the thighs ; while behind, 
they turn diagonally outward in order to pass over the tuberosities, 
which are best adapted for weight bearing. 



256 TUBERCULOUS DISEASE OF THE HIP JOINT. 

In the original Taylor hip brace the pelvic band is bolted to the 
upright in a manner to allow antero-posterior motion, and the inclina- 
tion of the pelvic band is regulated by a strap attached to the upright. 
(Fig. 176.) This facilitates adjustment when the limb is flexed to a 
marked degree. This brace has been modified by Taylor by shortening 
and changing the shape of the pelvic band for the use of but one peri- 
neal support (Fig. 201) ; and a similar form of brace is used by Judson. 
The shortened pelvic band lessens the restraint of the brace upon the 
motion of the limb, and seems to offer little compensating advantage. 

Before the traction brace is used in ambulatory treatment, distortion 
of the limb, if it be present, should be reduced; or if the disease be 
particularly acute, preliminary rest in bed, until the subsidence of the 
symptoms, is advisable. 

The Reduction of Deformity by Means of the Traction Brace. — The 
patient lies in bed upon a firm mattress ; the distorted limb is then 
raised to slightly more than a sufficient angle to relax the contracted 

Fig. 178. 




The reduction of flexion by means of the traction hip splint. (C. F. Taylor.) 

muscles and to straighten the lumbar lordosis ; it is then abducted or 
adducted if necessary so that the level of the pelvis is restored. The 
pelvic band is made to conform to this greater relative inclination of 
the pelvis by lengthening the posterior strap ; the brace is then applied, 
the limb being held in the attitude of deformity by a sling or support 
(Fig. 178), and as much traction as the patient can tolerate is exerted 
by lengthening the upright. The direct traction exerted by the brace 
may be reenlbrced by means of a cord running over a pulley at the foot 
of the bed, in the line of the brace, to which a weight of ten or more 
pounds (Fig. 1 79) is attached. Thus the pressure of the perineal bands 
is somewhat lessened. Efficient traction will quickly reduce recent de- 
formity caused by muscular contraction, and as this is lessened the posi- 
tion of the limb is correspondingly changed, until it lies extended and 
parallel with its fellow. If adduction be combined with flexion the 
perineal band on the side opposite to the disease is tightened from time 
to time, or a direct push against the opposite adductor region is exerted 
by means of a bar attached to the brace opposite the knee. (Fig. 200.) 



THE TRACTION BRACE. 257 

In ordinary cases the deformity may be reduced by this means in from 
two to six weeks. 

The brace should be worn day and night. The perineal bands may 
be loosened at times to allow for bathing the skin with alcohol, and for 
powdering, in order that the skin may be kept dry ; but at such times, 
if the disease be acute, manual traction should be made until the brace 
has been readjusted. The adhesive plasters, if of moleskin, may often 
remain in position for three months or longer. When they are re- 
moved the limb is gently bathed with alcohol. Excoriations are un- 
usual unless rubber plaster is used. If the skin is abraded the part 
should be powdered with boracic acid and protected from the plaster 
by a layer of gauze. 

* The Kelative Efficiency of the Traction Hip Splint. — 
In analyzing the action of this brace it is evident at once that it is 
thoroughly effective as a stilt. It is effective as a traction appliance, 
in the sense of relieving muscular tension, in direct proportion to the 

Fig. 179. 




A method of reducing flexion in hip disease. The brace is adjusted to the angle of deformity and 
in addition to the direct traction of the apparatus weights are attached to the brace itself. In the 
illustration counter-traction, by means of perineal bands attached to the head of the bed, is shown. 

<?are that is exercised in its adjustment. Traction by this appliance 
may be made constant and effective, even to the point of practical fix- 
ation while the patient is in bed, or when crutches are used, in ambu- 
latory treatment. But when the apparatus is used as a walking brace, 
as was designed by its inventor, constant traction is not exerted, for 
the traction straps alternately relax and tighten when the weight of 
the body falls upon and leaves the brace in walking. When the 
Ijrace is off the ground the joint is subjected to the traction that the 
brace exerts, plus its weight, as contrasted with cessation of traction 
and the relief from the Aveight when the brace supports the body at 
the alternate step. Thus the critics of the brace assert, in somewhat 
exaggerated language, that it exercises a pumping action on the joint. 
As a matter of fact, the observation of patients, under treatment by 
this method, will show that little actual traction is exerted in the ordi- 
nary cases ; that the so-called traction really serves principally for the 
adjustment of the brace, which by its weight, exercises a certain inter- 
mittent traction during locomotion. The hold of the encircling band 
17 



258 TUBERCULOUS DISEASE OF THE HIP JOINT 

upon the pelvis assures a considerable restriction of motion, but what- 
ever splinting action it may have depends upon the degree of traction, 
which is never effective enough, however, to prevent a certain amount 
of motion. This point is illustrated by the experiments of Lovett, 1 
which are described by him as follows : 

" In these experiments a long-traction splint was fitted with a self- 
registering pencil, by means of which motion at the hip joint was 
recorded upon the skin over the ilium. This was done simply by 
carrying the shaft up, so that it held the pencil perpendicularly to the 
skin. A splint fitted with this register was applied to a boy with 
normal hip joints, and traction was made up to the usual point, being 
about three pounds and a-half, as registered by a spring balance in- 
serted in the extension straps. With this splint on, the boy was 
allowed to walk, and it was found that the hip described an arc of 
thirty-five degrees of joint motion. In sitting down and rising, an arc 
of similar extent was described. In another case with normal hip 
joints the motion was found greater, and the register showed a motion 
of forty degrees. With a very severe amount of traction — so much so 
that it was almost unendurable — motion of fifteen degrees was recorded. 
This apparatus was first tested by being applied to a patient with 
anchylosis of the hip, when it was found that no motion was recorded, 
the register marking by a dot. These experiments certainly seem to 
show that to a healthy hip joint the long-traction splint affords very 
imperfect fixation, and it may be inferred that to a diseased joint 
equally poor support is afforded." 

The fact must be borne in mind that the traction hip splint was 
not intended to be a fixation or splinting appliance. On the contrary, 
Davis its inventor, Taylor, who changed it into a practicable form 
and Sayre, who further modified it, each believed that motion, except 
when the joint was fixed by muscular spasm, was desirable. 

"The first splint, as well as all my modifications, admits of free 
motion of the diseased joint, but rigidly excludes all friction of the 
diseased surfaces upon one another." 2 (Davis.) 

" Motion without friction is not only not injurious, but it is highly 
beneficial." 3 (Taylor.) 

"For the ligaments around a joint will become fibro- cartilaginous 
or even osseous, if motion is denied them, particularly if a chronic in- 
flammation is going on within the joint with which they are connected. 

" As Dr. Davis is, I believe, the first person who constructed an in- 
strument embracing these important advantages, extension with mo- 
tion, I have given him full credit for the same, etc." 4 (Sayre.) 

Motion without friction in this sense would seem to imply the actual 
separation of the femur from the acetabulum, or distraction as distinct 
from traction. 

iE. W. Lovett, N. Y. Med. Jour., Aug. 8, 1891. 

2 Davis, Conservative Surgery, 1867, p. 214. 

3 Taylor, The Mechanical Treatment of Disease of the Hip Joint, p. 15, 1873. 
* Sayre, Lectures on Orthopaedic Surgery, p. 260, 1879. 



THE TRACTION BRACE. 259 

That actual distraction is possible at the hip joint both in health 
and disease is proved by the experiments of Brackett l and by those of 
Bradford and Lovett. These experiments show that a traction force 
from ten to twenty pounds is required to cause one-eighth to one-quar- 
ter of an inch of actual lengthening of the limb, even in childhood ; it 
is, therefore, to say the least, unlikely that the feeble and intermittent 
traction exerted by a hip splint, when used as an ambulatory support, 
can be sufficient to separate the bones from one another and thus to 
allow motion without friction, as was originally claimed for this appara- 
tus. In fact it would appear that the claim that motion was of posi- 
tive benefit to the diseased joint was afterwards modified by the up- 
holders of this method of treatment to a negative assertion of its 
harmlessness, for example : 

" If the disease permits a certain amount of motion at the affected 
articulation, motion within the limits set by nature is not harmful." 2 
(Shaffer.) 

This statement would seem to imply that the motion permitted by 
the apparatus might be varied in accordance with the degree of re- 
striction that a particular case presented, provided that this motion 
were restricted to the limit set by nature ; but in actual practice the 
same form of brace is applied, and with the same adjustment, in every 
case ; or as it is stated in a paper on the final results of the mechan- 
ical treatment by this apparatus in dispensary practice, under Shaf- 
fer's direction : " In each case reported, a Taylor traction splint was 
applied soon after the first examination. * * * The patient, unless re- 
cumbency was necessary to overcome a malposition of the limb or un- 
less the symptoms were so acute as to demand rest, was allowed almost 
unlimited exercise in the open air." 3 Yet it may be inferred from the 
report of the final results in these cases that in spite of the protection, 
which in many instances must have restricted motion within the limits 
present at the first examination, the range of motion became more and 
more restricted, for in 16 of 35 cases reported, anchylosis resulted ; 
and in seven others the motion was less than ten degrees. Thus in 
74 per cent, of the cases, practical fixation of the joint was found on 
the final examination. 

In criticising these statistics it must be borne in mind that the pa- 
tients were treated under all the disadvantages of dispensary practice, 
and that the final usefulness of a limb is by no means in proportion to 
the freedom of motion that may be preserved ; still with these reserva- 
tions it can hardly be claimed that the proportion of absolute or par- 
tial anchylosis would have been greater than this had any other system 
of treatment been employed. 

At the present time the theory that motion of a diseased joint is of 
benefit, or that it is even harmless, has few supporters even among 

brackett, Trans. Am. Orth. Ass'n, Vol. II.; Bradford and Lovett, N. Y. Med. 
Jour., Aug. 4, 1894. 

2 Shaffer, Trans. Am. Orth. Ass'n, Vol. II., p. 100. 

3 On the Ultimate Kesults of the Mechanical Treatment of Hip Joint Disease. 
Shaffer and Lovett, N. Y. Med. Jour., May 21, 1887. 



260 TUBERCULOUS DISEASE OF THE HIP JOINT. 

those who use the traction brace exclusively. On the contrary, the 
motion that is recognized as unavoidable with the use of the apparatus 
is excused because of the practical efficiency of the brace and because it 
is believed that no more effective rest can be attained by any other 
method of ambulatory treatment. 

In all acute cases a period of rest in bed with traction to the point 
of actual distraction, is advised. When ambulation is resumed the 
braced limb is made pendant by means of the high shoe and crutches, 
so that uninterrupted traction may still be exerted, and the brace is 
only used as a supporting appliance when the symptoms indicate that 
the disease is quiescent. 

Although this modification of treatment was not followed by Tay- 
lor, still in his later writings he states that motion is of advantage 
only in the stage of recovery. And it is very evident that his success 
was due to the extreme care which he exercised in the supervision of 
the patients, and in adapting treatment to the varying phases of the 
disease, rather than to any theory that he may have advocated. 1 

As has been stated, treatment by the long-traction brace by means 
of which motion without friction was at one time claimed to be possi- 
ble, and in which traction is the distinctive feature, is sometimes called 
" The American Treatment of Hip Disease." In this sense, the direct 
splinting of the joint without traction, by means of the Thomas brace, 
might be called in distinction " The English Treatment." 

The Thomas Treatment of Hip Disease. — H. O. Thomas, 2 of Liverpool, 
writing at a time when in America it was generally believed that motion 
was essential to the well-being of a diseased joint, and when fixation 
was supposed to predispose to, or to actually induce, anchylosis, states 
" that continuity of extension per se is not a remedy in hip joint disease ; 
in its application it involves unavoidably a fractional degree of fixation 
which is sufficient to mask the evil of this ridiculous malpractice." 

The conclusions on which his treatment is founded are these : " The 
main obstacle to the cure of an inflamed joint is the friction and pressure 
of its surfaces ; consequently the attainment of rest, that is of immobility 
of the articulations, ought to be the principle which should guide the 
treatment. Pressure and concussion are less to be feared than friction. 
Effectual rest can only be obtained by mechanical treatment and for 
this purpose the appliances which I here recommend are effectual. 
The more an inflamed joint is moved the stiffer does it become ; while 
the more effectually it is fixed, the sooner and the more completely is its 
capability of movement restored. To insure permanency of cure, the 
control should be maintained for a period beyond the time when resolu- 
tion has taken place. This prolonged arrest of a joint's movements, for 
even an unnecessarily long period, I have never found to do harm." 

The splint used by Mr. Thomas to carry out these principles effec- 
tively is described by him substantially as follows : 

1 Boston Med. and Surg. Jour. , March 6, 1879. 

2 Diseases of the Hip, Knee and Ankle Joints, treated by a new and effective 



THE THOMAS BRACE. 



261 



A flat piece of malleable iron, three-quarters of an inch wide and 
three-sixteenths of an inch thick for children, and one inch by one- 
quarter inch for adults, long enough to extend from the lower angle of 
the scapula to the middle of the calf, forms the upright. This is 
fitted to the body of the patient, passing from the lower angle of the 
scapula, in a perpendicular line, downward, over the lumbar region, 
across the pelvis, slightly external, but close to the posterior spinous 
process of the ilium and the prominence of the buttock, along the 
course of the sciatic nerve to a point slightly internal to the calf of 
the leg. It must be carefully modelled to this track. The lumbar 
portion of the upright must be invariably almost 
a plane surface, but it must be twisted slightly on 
its long axis at the junction of the upper and 
middle third, so that the anterior surface of the 
lower section may look slightly outward to cor- 
respond to the contour of the buttock and thigh. 
A second and double bend is made in the upright 
at the point where it passes the buttock, so that the 
thigh portion lies on a slightly higher plane than 

Fig. 181. 



Fig. 180. 





The splint in its simplest 
form, not yet padded or cov- 
ered. (Ridlon.) 



The Thomas hip splint, covered and fitted with shoulder straps. 
(Ridlon and Jones.) 



the body part, but parallel with it. The upright is then provided with 
chest, thigh and leg bands. 

The chest band is of hoop iron one and a-half by one-eighth of an 
inch. This is bent into an oval to correspond with the shape of the 
chest, being four inches less than its circumference at this point if the 
patient be an adult, and of a corresponding size for a child. This 
band is riveted to the upper extremity of the brace, so that one-third 
of its length shall be on one side of the disease and two-thirds on the 
other. The thigh band and leg bands are of similar material, three- 
quarters by one-eighth of an inch in size. The thigh band, in length 
equal to two- thirds of the circumference of the thigh, is fastened to the 
upright at a point one to two inches below the buttock, and the calf 
band, equal in length to half the circumference of the leg at the calf, 



262 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



is riveted to the lower extremity of the brace. Both the thigh and leg 
bands are attached to the brace at points slightly to the inner side of 
the center, so that the outer arm of each band is somewhat longer than 
the inner. The brace is padded with thin boiler felt and is covered 
smoothly with basil leather. In fitting the brace to the patient the 
long part of the chest band should be made to hug the body closely, 
while the short arm should be somewhat away from it. The anterior 
surface of the thigh part of the upright should have a perceptible out- 
ward twist and should be somewhat on the inner side of the popliteal 
space. Thus the instrument is prevented from rotating outward and 
becoming a side splint. The chest band is closed with a strap and 
buckle and suspended by shoulder straps and the leg between the two 

Fig. 182. 




Method of changing the line of pressure on the skin from the Thomas hip splint. (Ridlon and Jones. ) 

bands is attached to the brace by means of a flannel bandage. Ridlon 
states that in practice this bandage is usually replaced by a strip of 
basil leather passed across the front of the leg close down to the upper 
border of the patella, thence backward and downward to the stem of 
the splint and pinned to the covering, so that any downward working 
of the splint would be brought to bear on the quadriceps femoris mus- 
cle. The shoulder straps also may be replaced by a single bandage 
looped about the upper part of the stem. (Fig. 182.) This bandage is 
twisted for a length of about six inches, then separated, the ends being 
carried over the shoulder, passed through holes in the corresponding 
ends of the chest band where they are knotted, and finally the two ends 
are tied to one another completing the circumference of the chest band. 
This brace is fitted by the surgeon directly to the patient's body as 



THE THOMAS BRACE. 



263 



he stands erect. If the limb be already flexed, the foot is raised by 
blocks until the lumbar lordosis is straightened ; the brace is then ad- 
justed to the angle of deformity and is applied in the usual manner. 

The brace is made of iron because it is less elastic than steel and 
because it can be more easily twisted by wrenches. It must be heavy 
and strong in order to splint the part effectively and it can only be an 
effective splint when it is fixed in its proper position and exercises 
direct pressure upon the hip joint. In cases in which the brace has 
been properly employed a deep furrow should be seen in the buttock 
directly over the neck of the femur. Once fitted to the patient it is 
changed only at intervals and always by the surgeon who is particularly 
careful not to move the limb during the active stage of the disease. 

The double Thomas hip splint is made by joining two single splints. 
These are riveted to the chest band above and are connected at the 
lower ends by a crossbar, unless the brace is to be used in the reduc- 
tion of deformity. Care must be 
taken that the uprights pass to the 
outer side and not directly over the 
posterior superior spines of the ilium. 

The Reduction of Deformity by the 
Thomas Method. — Preferably in the 
treatment of children the double 
brace is applied, the sound limb being 
fixed in the extended position while 
the flexed limb is supported by the 
other arm of the brace, bent to the 
angle of deformity. The patient is 
confined to the bed and as the mus- 
cular spasm relaxes under the in- 
fluence of enforced rest, the brace is 
straightened slightly by wrenches 
from time to time, at a point opposite 
the joint, to conform to the improved 
position until symmetry is restored. 
In resistant cases this gradual relax- 
ation is hastened by straightening the 
brace somewhat at intervals, to which 
the attached leg must conform — a 
gradual forcible reduction of de- 
formity. 1 

The treatment is divided by Mr. 
Thomas into stages. 

1 . A preliminary stage of rest in 
bed for the reduction of deformity and to allow for subsidence of 
acute symptoms. 

" Ridlon forces the flexed limb to conform to the straight Thomas brace unless the 
deformity is extreme. This is made possible by an exaggeration of the lumbar lordosis 
and by a corresponding increase of intra -articular pressure as illustrated by Marsh's 
diagram (Fig. 183). 




Thomas splint applied with patten and crutches. 



264 



TUBERCULOUS DISEASE OF THE HTP JOINT. 



2. The patient is then allowed to go about on crutches wearing an iron 
patten at least four inches in height under the sound foot. (Fig. 183.) 

3. When all symptoms of disease have subsided and when atrophy 
of the muscles is marked the brace may be removed at night. 

4. The brace is finally discarded but the patten and crutches are 
still used in walking. 

According to Ridlon ! the records of Mr. Thomas show the average 
time of confinement to the bed to be twenty-two weeks, and the aver- 
age duration of treatment twenty-one months. 

It is stated by Ridlon 2 that in actual practice these principles were 
not carried out, for nearly all the children treated under Thomas' 
direction at the time his observations were made, were walking about 
without the high patten and crutches, even before the deformity had 
been overcome and while muscular spasm and pain persisted. 

This was, however, probably an exigency of practice among the 
poor, and at all events it is in line with Thomas' contention that 
pressure and concussion are less harmful than friction. 

Modifications of the Thomas Brace. — Although not so stated in his 
book, Thomas used at times a short brace extending only to the 
lower part of the thigh, thus permitting motion at the knee. This 
was apparently designed as a convalescent splint, although its use was 

Fig. 184. 




A form of Thomas brace employed in the treatment of infants. The screws at the lower extremity 
are arranged to permit the addition of a foot piece for traction. 



not restricted to that class of cases. In certain cases a strip of iron, 
" the nurse/' was screwed to the lower extremity of the long brace, 
prolonging it beyond the foot in order to prevent the patient from 
bearing weight upon the limb. 

The Thomas brace, so effective in preventing and overcoming flexion 
deformity, is correspondingly inefficient in antagonizing lateral distor- 
tion. In fact in twenty-four of the fifty-eight patients examined by 
Ridlon, 8 adduction was present ; a larger proportion, it would appear, 
than would be found in a like number of cases under treatment with 
the traction brace. This tendency to lateral distortion may be guarded 

1 Trans. Am. Orth. Ass'n, Vol. I., p. 17. 

2 A report of 62 cases of Hip Disease observed in the practice of Hugh Owen Thomas. 
N. Y. Med. Jour., Oct. 4, 1890. 

3 Loc. cit. 



THE SPICA BANDAGE. 



L'65 



against by placing a half band of material similar to the chest band, 
about the side of the pelvis ; on the same side for adduction, on the 
opposite side for abduction of the limb. 

The Thomas brace has a great advantage over other appliances in 
its simplicity. It can be made by a blacksmith and it must be fitted 
by the surgeon. This fitting requires great care. In the words of 
Mr. Thomas, " the fitting al- 
though sometimes successful in Fig. 185. 
one visit, may at other times 
occupy many days. The surgeon 
should mould, by reducing or 
increasing the various curves, 
until the instrument ceases to 
tend to rotate, and at none of its 
angles irritates the patient." He 
concludes in a general answer to 
the criticisms that have always 
been made on the difficulty of 
adjustment of the appliance, as 
follows : " What I can invari- 
ably do must be possible to 
others." 

Treatment by the Plaster Band- 
age. — A third method of treat- 
ment is that by means of the 
plaster bandage without crutches 
or high shoe. This is simple 
splinting with whatever protec- 
tion from concussion the sup- 
port may assure. 

This treatment might be called 
the German method, if the trac- 
tion hip splint and the Thomas 
brace are to be designated as 
American and English. 

As used in the Surgical Clinic 
at Berlin, the plaster bandage is 
applied from the line of the nip- 
ples to include the foot, the limb 
being fixed in an attitude of 
slight flexion, abduction and out- 
ward rotation. As a rule the 

first bandage is applied under anaesthesia for the purpose of relaxing 
the muscular contraction and facilitating the application. If nutritive 
shortening of the muscles is present, sufficient force is employed to 
overcome the deformity. The spica is renewed at intervals of from 
two to four months. When the disease is cured and the bandage is 
finally removed, traction at night is employed for a time, by means of a 




A plaster spica bandage. 'I lie dotted line indi- 
cates the position of the steel support. 



266 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



weight attached to the foot, to prevent the tendency to distortion. In 
ambulatory treatment this method has little to recommend it except ex- 
pediency, but as a temporary support to be used before the application 
of a suitable brace, the plaster spica is most useful. 

The plaster of Paris spica bandage when properly applied, is an ad- 
mirable support, often far more comfortable to the patient than any 
splint, and it is at times an indispensable form of dressing. It is criti- 
cised for the same faults as the plaster jacket and it may receive the 
same defense, that the most severe critics have had the least experience 
in its use. 

Application of the Plaster Spica Bandage. — A plaster bandage to as- 
sure support should fit perfectly, consequently it should be applied as 
closely as is possible, directly upon a layer of canton flannel, in place 
of the thick sheets of cotton wadding that are often used to envelop 
the body and the limb ; only the bony prominences of the ilium, the 
knee and the heel require other protection. The bandage should cover 

Fig. 186. 




A modification of the Lorenz hip rest used at the Hospital for Ruptured and Crippled in the applica- 
tion of the plaster spica bandage. 



the lower half of the thorax, and it should extend to the ends of the 
toes. It should be applied under slight extension, drawn closely 
around the adductor region and the buttock, which should be entirely 
covered and supported. At this point, in the line in which the bar of 
the Thomas hip splint runs, a piece of splint wood or a strip of malle- 
able steel, long enough to reach from the middle of the back to the lower 
third of the thigh, should be incorporated in the plaster. (Fig. 185.) A 
similar piece is sometimes placed in front of the hip and another beneath 
the knee, the points at which the bandage is likely to break. The 
proper support of the buttock, consequently of the hip joint, is almost 
invariably neglected in the ordinary application. The bandage may 
be applied in the upright posture by means of the swing, as used in the 
application of the plaster jacket, the weight being supported in part by 
the sound leg while the other is pendant. Or it may be applied with 
the patient in the reclining posture, the body being supported by a 



REDUCTION OF DEFORMITY 



267 



shoulder rest, and the pelvis by the sacral support of Lorenz. The 
arms are then drawn above the head to increase the capacity of the 
thorax, while the two legs are supported by an assistant. (Fig. 187.) 

In the more recent cases, deformity may be practically reduced at 
the second application of the bandage, because of the relaxation of the 
spasm assured by the rest and fixation ; thus it is particularly useful in 
the treatment of young children in the outdoor practice, for whom 
hospital care would otherwise be required. 

Immediate Reduction of Deformity. — In the more resistant 
cases an anaesthetic may be administered. If the deformity be due sim- 

Fig. 187. 



.160/ 




The hip rest iu use. The patient presents fixed flexion to 135 degrees and fixed adduction 

of 35 degrees. 

ply to muscular spasm the limb may be placed in the proper position 
without force, but if, as is often the case when the distortion is of long 
standing, it is caused in part by shortening of the muscles and fasciae, 
a certain amount of force may be required. The pelvis should be 
fixed and the force should be applied as far as possible by direct ex- 
tension rather than by leverage. Subcutaneous division of the con- 
tracted tissues about the anterior superior spine and in the adductor 
region, may be required. In very resistant cases the reduction of de- 
formity by this method should be divided into several operations. 
Lorenz l reduces the adduction deformity by means of a machine that 

1 Lorenz, Sammlung Klin. Vor., 206, Leipzig, March, 1898. 



268 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



exercises direct traction on the addncted limb while the sound limb is 
pushed upward, so that practically no leverage is exerted on the joint. 
In cases in which the deformity is accompanied by abscess, or when 
the joint is surrounded by infiltrated tissues and by sinuses this treat- 
ment should not be employed. In fact in certain cases of this class, 
especially when subluxation is present, it is often advisable to disre- 
gard the deformity that cannot be reduced by traction until the disease 
is cured, when it may be overcome by osteotomy of the femur. (See 
page 293.) 

The immediate reduction of deformity by this method, properly per- 
formed, is free from danger ; and it has become almost the routine of 
practice in the indoor department of the Hospital for Ruptured and 
Crippled. It has the great advantage of permitting the limb to be 
fixed iu the proper position during the stage of recumbency, instead of 
employing this time for its gradual reduction. 

Three methods of reduction of deformity have been described : 

1. By means of the traction splint. 

2. By means of the Thomas brace. 

3. By means of the plaster bandage, with or without anaesthesia. 

A fourth method is that by means of the weight and pulley. This 
is in common use because it requires no special apparatus. 

Fig. 188. 




Posture of the limb in hip disease in which extension acts as leverage, p, pulley ; 
w, weight ; /, fulcrum. 

Reduction of Deformity by the Weight and Pulley. — The 
traction plasters are applied to the limb in the manner already de- 
scribed and the patient is placed on his back on a narrow firm mat- 
tress. The limb is then raised until the lumbar vertebrae rest upon 

Fig. 189. 



i 



w 



Weight extension acting as leverage in hip disease, p, pulley ; w, weight ; /, fulcrum. 

Marsh's diagrams, illustrating the advantage of traction in the line of deformity, in order to avoid 

leverage. (Howard Marsh.) 



the bed and it is then moved to one or the other side, if lateral distor- 
tion be present, until the level of the pelvis is restored. In this posi- 
tion the limb is supported on a pillow, or better on the adjustable tri- 



REDUCTION OF DEFORMITY. 



269 



angle used with the traction hip splint. (Fig. 178.) A pulley or wheel 
is then attached to the foot of the bed in a prolongation of the line of 
the elevated leg. This wheel may be screwed to the top of a narrow 
board, which may be raised or lowered on the foot of the bed as required. 
To the buckles on the plaster traction straps a stirrup carrying the 
cord is attached. This stirrup is simply a spreader of narrow thin 
wood, slightly wider than the foot, provided at either end with straps 
or tapes, its purpose being to prevent direct pressure on the malleoli. 
(Fig. 193.) By means of a weight suspended at the bottom of the bed 
traction is made upon the limb to the extent that the comfort of the 
patient will permit. As in Buck's system of extension, the foot of the 
bed is raised to increase the friction of the body and thus to counteract 
the traction force, but in the treatment of children this is inefficient and 
counter traction must be provided. A simple method is to attach two 
perineal bands, as described in connection with the traction brace, to 
strong tapes that pass above and below the patient's body, to be fixed 



Fir;. 190. 




Extension in hip disease. Marsh's method of fixing the patient in bed with shoulder straps and a 
long T splint on the sound side. (Howard Marsh.) 

to the head of the bed at a suitable distance from one another, thus 
the pelvis is supported by prolonged perineal bands. 

In order to assure efficient and constant traction the patient must be 
prevented from sitting up. For this purpose a swathe about the body, 
or shoulder straps may be applied and attached to the bed. 

A convenient appliance is that of Marsh. " This consists of a piece 
of webbing, passing across the front of the chest, and ending in two 
loops, through which the two arms are passed, and through which is 
threaded another piece of stout webbing, which runs transversely 
across the surface of the bed under the child's shoulders, and is fastened 
at its two ends to the sides of the bedstead. When this is in action 
the patient's shoulders are kept flat on the bed, so that he can neither 
sit up nor turn on his side. This chest band does not cause the slightest 
discomfort. It is not, of course, fixed tightly, and when the child 
finds that he cannot sit up, he makes no further attempt to do so ; and 
as he lies flat the band is loose." 



270 



TUBERCULOUS DISEASE OF THE HIP JOINT 



It is better however to use some form of apparatus to fix the patient 
more thoroughly. Marsh uses a long lateral splint of thin board 



Fig. 191. 




Traction by means of weight and pulley. (R. T. Taylor.) 

reaching from the axilla to a point below the sole of the foot where a 
crossbar is attached. To this the patient's body and sound limb are 
bandaged. (Fig. 190.) 



Fig. 192. 




Method of fixing the patient to the Bradford frame for traction in hip disease. (R. T. Taylor.) i 

A plaster spica bandage or a Thomas splint may be employed on 
the sound side, but the most convenient appliance is the frame of gas 



LATERAL TRACTION. 271 

pipe covered with canvas, that has been described in the chapter on 
Pott's disease. Upon this frame the patient can be fixed, the limb 
being elevated by a support attached to the frame or independent 
of it. (Figs. 191, 192.) It is perhaps needless to suggest that the bed 
clothes must be held from the elevated limb, in fact, that the patient 
must for a time be enclosed in a tent of bed clothes, if the deformity 
is extreme. At first the traction weight must not be great, but as the 
perineum becomes accustomed to pressure, as much weight as can be 
tolerated is used, from ten to twenty pounds being the average. This 
may be reduced at night and increased during the day. Great care 
must be taken to prevent painful pressure on the perineum by careful 
adjustment and frequent inspection of the perineal bands. 

If the frame is used it may be provided with a windlass at the bot- 
tom for traction and with an arched band of metal across the pelvis 
for the attachment of the perineal bands which behind are fastened to 
the side bars at a higher level. Thus the frame may be made an in- 
dependent recumbent splint on which the patient may be moved about. 
If, however, one desires to exert traction to the point of distraction, 
the weight and pulley arrangement will often be required ; in this case 
the limb should be placed in an attitude of slight flexion and abduction 
so that the femur may be drawn more directly from the acetabulum. 

Fig. 193. 




Lateral and longitudinal traction in hip disease. (Page.) 

Lateral Traction. — Thus far longitudinal traction has been consid- 
ered, but lateral traction or traction in the line of the neck of the 
femur deserves some consideration. 

Mr. Thomas, who condemns all forms of traction as deceptive and 
irrational, and especially longitudinal traction, speaks thus of lateral 
traction. " For surely if relief from pressure be required, the only 
direction in which this is possible is clearly in the axis of the neck of 
the femur. Any method of extension in the axis of the body merely 
transfers the pressure from the upper part of the acetabulum to the 



272 TUBERCULOUS DISEASE OF THE HIP JOINT. 

lower quarter." l This contention is purely theoretical as there is no evi- 
dence to show that injurious pressure is ever exerted upon this part of the 
acetabulum. On the contrary, the specimens from subjects who have 
been treated by longitudinal traction in recumbency and by means of 
the traction hip splint, almost invariably show the effect of pressure 
upon the upper part of the head of the femur and upon the upper ad- 
joining margin of the acetabulum. Moreover, the neck of the femur 
is in childhood so short and is set upon the shaft at so great an angle, 
that longitudinal traction, if the limb be slightly abducted, is prac- 
tically speaking in the line of the neck ; so that even from the the- 
oretical standpoint, the question of injurious pressure could only arise 
in the treatment of adults. The advantages of lateral traction in the 
treatment of hip disease have been urged with great persistency by A. 
M. Phelps, 2 since 1889, and it has been applied as a routine practice 
in ambulatory treatment by Blanchard, 3 of Chicago, since 1872. 

The effect of lateral traction in recumbency has been carefully in- 
vestigated by C. G. Page. 4 His conclusions are that lateral traction 
alone is of no benefit, but if applied, together with longitudinal trac- 
tion, it gives great relief in some acute cases. The longitudinal trac- 
tion should be twice as great as the lateral, ten and five pounds being 
the average weights employed in his experiments. The method is 
shown in the illustration. (Fig. 193.) 

The Relative Efficiency of Traction and Splinting (" Fixation "). 

In considering the vexed question of the relative merits of splinting 
and traction in preventing muscular spasm and the consequent intra- 
articular pressure which causes pain and increases the destructive ef- 
fects of the disease, these facts must be borne in mind. 

The more acute the disease the less the ability of the joint to carry 
out its proper function, which is motion. The greater the motion 
under these circumstances the more intense the muscular spasm of 
which the object is the prevention of motion. If it were possible there- 
fore to fix the joint absolutely there should be no muscular spasm, 
although the tension of acute disease within the bone, or of its products 
within the joint, might cause pain. 

When the patient is fixed in the recumbent posture it is possible to 
apply a sufficient traction upon the muscles to prevent the contraction 
that causes injurious pressure, and although no amount of traction will 
absolutely prevent motion, yet with the support that the bed provides, 
practically speaking, complete rest may be assured. Only in the excep- 
tional cases in which the tension upon congested tissues about an acutely 
inflamed joint is intolerable is this method of treatment inefficient. 

The same statement is true of a properly applied spica bandage or 
Thomas brace, when the patient is recumbent, that it assures practical 
rest ; thus it prevents muscular contraction, relieves the symptoms and 

iLoc. cit, p. 10. 2 N. Y. Med. Becord, May 4, 1889. 

3 Trans. Am. Orth. Ass'n, Vol. VII. 

4 C. G. Page, Bost. Med. and Surg. Journal, Sept. 13, 1894. 



RELATIVE EFFICIENCY OF TRACTION AND SPLINTING. 273 

promotes repair, although it cannot be claimed that the surfaces of the 
opposing bones are actually separated from one another. 

But what is true when the patient is recumbent is not true of am- 
bulatory treatment. The traction exerted by the hip splint even when 
the limb is pendant is far less effective than in recumbency, and when 
it is used as a walking appliance, for which it was designed and for 
which it is practically always employed, the traction is intermittent 
and of doubtful efficiency. The same loss in efficiency in less degree 
occurs in all forms of fixative apparatus when used in ambulation. 

The Removal of Direct Pressure — " Stilting." — But granting that the 
traction brace as a walking appliance is relatively inefficient in pre- 
venting motion, and that motion without friction, provided the joint 
surfaces are actually involved, is impossible, still it cannot be denied 
that the traction brace is, or may be, at all times an effective stilt in 
that it protects the joint from concussion and pressure by removing the 
foot from contact with the ground. 

It is true that the removal of direct pressure may be attained by 
the use of axillary crutches, but in Thomas' practice, they were used 
in but few cases. 1 In fact it is only by constant supervision that the 
use of crutches can be enforced upon children who no longer suffer pain, 
and as it is practically impossible to prevent the patient from bearing 
weight upon the limb, stilting by this means is relatively inefficient. 

That direct pressure is one of the causes of upward displacement of 
the femur may be inferred from the statistics of Sasse and Bruns, 2 from 
the surgical clinics of Berlin and Tubingen where the routine of treat- 
ment is the plaster bandage, without the high shoe or crutches. In 
two-thirds of Sasse's and in four-fifths of Bruns' cases there was up- 
ward displacement of the trochanter. This is certainly a larger pro- 
portion than would be found in a corresponding class of patients treated 
by efficient stilting, although statistics on this point from American 
sources are lacking. 

In the final comparison of the claims of traction and fixation, 'it is 
of interest to note that the most enthusiastic advocate of the Thomas 
treatment in this country, was trained in the use of the traction hip 
brace at the New York Orthopaedic and Dispensary Hospital, an in- 
stitution founded by Taylor and in which his methods have been 
closely followed. Ridlon states that an experience in the treatment of 
eleven hundred cases by the traction hip splint, led him to discard it 
in favor of the Thomas brace. 3 

The Practical Combination of Traction — Splinting and Stilting. — 
Thus far, the methods of treatment by splinting and traction have 
been presented as if they were necessarily opposed to one another in 
principle, and as if the theory were still held, that motion without 
friction is possible ; and as if it were believed that anchylosis is caused 

1 Ridlon, loc. cit. 

2 Sasse, Arbeit aus der Chir. Klin., Berlin, 1896. Bruns, Archiv. fur klin. Chir., 
Bd. 48, H. 1. 

3 Ridlon, Trans. Am. Orth. Ass'n, Vol. II. 
18 



274 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



by fixation and is prevented by the motion of a diseased joint. At 
the present time, however, it is generally recognized that the principle 
involved in both methods is the same, and that the actual merit of 
each must be decided by practical experience rather than by argument. 
The true test of the relative value of a routine of treatment is its effi- 
cacy in hospital practice, where its weak points cannot be supplemented 
by the careful supervision that may make almost any treatment that 
carries out in some degree the proper principle, effective. This test 
is all the more necessary because the great majority of cases of this 
character are to be found among the poor. 

From this point of view the writer's experience may be of interest. 
His early training was entirely in the traction method, but the obser- 
vation of a large number of cases in which this treatment was used, 
led to the following conclusions. 

In one sense the treatment was successful, in that it in great degree 
relieved the symptoms throughout the greater part of the course of the 
disease and enabled the patients to go about in the open air, to attend 

Fig. 194. 




The short spica bandage in combination with the brace, one perineal band has been removed in or- 
der to show how the joint is supported by the bandage. 

school and even to join in the games of their fellows. It was evident 
however, from an inspection of the patients as they returned for treat- 
ment, that the relief of symptoms was due to the protection insured by 
the stilting or crutch-like action of the brace and not by the traction, 
which was usually simply traction in name, not in fact. But if the brace 
relieved symptoms, it did not, in many instances, prevent deformity ; 
and as the prevention of deformity is an object only secondary in im- 
portance to the relief of pain, the treatment was in so far unsatisfac- 
tory. This deformity was usually flexion, occasionally combined with 
adduction, a deformity often increasing slowly without pain, or other 
evidence of greater activity of disease. If the deformity were reduced 
by traction in recumbency, it reappeared when ambulatory treatment, 
by the brace, was resumed. This flexion seemed to be in many in- 
stances simply an adaptation to the prevailing postures. When, for 



RELATIVE EFFICIENCY OF TRACTION AND SPLINTING. 



/o 



Fig. 195. 



example, the patient assumed the sitting position, the limb was flexed 
in spite of the brace, and as much of the time was passed in this atti- 
tude, its influence on the production of deformity seemed to be ob- 
vious. It was also apparent that the brace was not effective in relieving 
pain during the more acute exacerbations, even during recumbency 
with such traction as could be applied by the parents ; nor when the 
children were brought in arms to the Clinic. 

It is doubtless true that with proper nursing and proper care the 
apparatus might have been efficient, but the conditions were other- 
wise. Under these conditions it was found that acute symptoms might 
be relieved, or greatly modified, al- 
most at once, by the application of 
a close-fitting short spica bandage 
extending from the middle of the 
thorax to the knee. Over this the 
brace was applied as before, making 
an apparatus which then combined 
splinting, traction and stilting. (Fig. 
194.) This treatment was repeated 
in many instances, always with the 
same result. As the application of 
the plaster bandage was a some- 
what tedious proceeding, it was 
often exchanged for a short Thomas 
splint worn beneath the pelvic band 
of the traction brace in the same 
manner. This fixation appliance 
not only relieved pain in the acute 
cases, but it also prevented the de- 
formity, which was not checked by 
the traction brace alone. 

This combination of the Thomas 
brace and the traction hip splint, 
is the most effective mechanical 
means of relieving pain and pre- 
venting deformity, that can be em- 
ployed in ambulatory treatment. It 
has, however, the disadvantage of 
requiring careful adjustment, and 
it obliges the patient to wear shoul- 
der straps ; in other words much 
care must be exercised to insure the 
comfortable adjustment of both appliances. Thus the next step was 
the combination of the two, even though the action was somewhat less 
effective. To the pelvic band of the traction brace a lateral thoracic bar 
was attached reaching upward in the axillary line to a point opposite 
the middle of the scapula, where it was joined to a metal band that en- 
circled the chest, like that of the Phelps brace. When this was securely 




The long inexpensive brace with solid up- 
right showing the perineal bands and the ad- 
hesive plaster, as used in hospital practice. 



276 



TUBERCULOUS DISEASE OF THE HIP JOINT 



fastened about the chest, the body and the limb were held in line by a 
long lateral brace ; the pelvis was supported by the pelvic band and the 
joint received the additional protection that was assured by traction 
and stilting. l (Figs. 195 and 196.) 

This brace and another form similar in principle, in which the up- 
right of the thoracic attachment is fixed posteriorly to the pelvic band, 
are now in general use at the Hospital for Ruptured and Crippled. 
The efficiency of this brace may be still further increased by replacing 
the perineal bands by a metallic ring. This ring, which fits the upper 
extremity of the thigh closely, is attached to the upright at an inclination 
corresponding to the line of the groin. (Fig. 197.) (The Thomas ring 
described fully in connection with his knee splint.) It is a better sup- 
port because it prevents antero-posterior motion within the pelvic band, 
which the perineal straps allow. The ring may be used as the only 
support or it may be combined with a perineal band on the opposite 
side. This is of advantage if there is a tendency toward adduction. 

The apparatus is most satisfactory when the hollow upright of the 

Fig. 196. 




The long hip splint applied. 

Taylor brace is used. This is light and strong and is provided with 
an arrangement for effective traction, but in hospital practice the up- 
right is made of solid metal, and the traction is adjusted by simple 
straps. The metallic ring, besides providing better fixation, is a firm 
support that can not be disturbed by the patient. It is of course more 
difficult of adjustment, and it is not suited to the treatment of young 
children because of the difficulty in keeping it clean and dry. 

The Thomas ring was first applied to a hip splint by Phelps. (Fig. 
199.) He has always urged the advantages of fixation and traction, 
and his brace, of which that last described is simply a slight modifica- 
tion, is supplied with an arrangement for lateral traction. Practically 
speaking, this is a tape by which the lower third of the thigh is held 
in apposition to the upright. It hardly seems possible that appreciable 
lateral traction can be exerted on the joint by this means, and certainly 
none whatever if the metallic ring is properly fitted to the thigh. The 
simple straps do not afford as effective traction as the rack and pinion 

1 Kidlon at one time used a brace identical with this (Trans. Colorado Med. Soc, 
1895) but Phelps appears to have first described a form of brace with a thoracic sup- 
port in the axillary line. 



RELATIVE EFFICIENCY OF TRACTION AND SPLINTING. 277 

nor is the brace, as usually constructed, sufficiently strong to bear the 
weight of the body without bending. It should be stated, however, 
that this form of brace is intended to be used with crutches rather 
than as a walking appliance. 

Many objections to this attempt to combine the two methods of 



Fig. 19. 



Fig. 198. 



1 


Ural 

m 




The long brace with Thomas ring and exten- 
sion upright, similar to Phelps' brace. 



Rear view of brace. 



treatment in one appliance have been urged by those who believe in 
the efficiency of the traction brace. For example, it is said that the 
splinting is ineffective because the movements of the trunk are trans- 
mitted to the joint, while this is not true of braces that do not extend 



278 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



above the pelvis. In reply it may be stated that the traction part of 
the combined splint remains as effective as before ; thus it follows that 
this suggestion is an acknowledgment of the fact that the theory of 
motion without friction is no longer tenable. As a matter of experience, 
however, it will be found that motion of the upper part of the trunk is 
absorbed, as it were, in the flexible lumbar region of the spine, before it 
reaches the joint. If, however, such motion or any motion causes dis- 
comfort or aggravates the symptoms, the patient should be confined in 
the recumbent posture until the acute 
phase of the disease is passed. Fig. 200. 

It is said that the brace is cumber- 



Fig. 199. 





The Phelps hip splint. 



A chair to be used with the long 
hip splint. The patient sits upon the 
sound side, while the splinted half of 
the body remains in the extended po- 
sition, the brace resting on the floor. 



some, that the patient can not sit with comfort, and that it prevents 
normal activity. 

A long brace certainly weighs more than a short one, and if a brace 
prevents flexion at the hip and spine, it is evident that the patient can 
not sit with comfort in an ordinary chair. 

As a matter of fact the patients themselves make little complaint of 
the brace, even when it has been substituted for an ordinary traction 
splint ; while the greater restraint of activity is a favorable element of 
treatment, since children who do not suffer pain are much more likely 
to be too active than to be restrained by any form of appliance. These 
objections are trivial, if one is convinced that the dangerous and de- 



RELATIVE EFFICIENCY OF TRACTION AND SPLINTING. 279 

forming disease that is under treatment may be more easily controlled 
and that the final result is likely to be better and to be more rapidly 
attained by this means than by another. 

This form of brace is used exactly as is the ordinary traction brace. 
If deformity be present it is reduced by one or another of the methods 



Fig. 201. 



Fig. 




The Taylor hip splint as 
used by Taylor in the later 
years of his practice with 
but one perineal band. 

The cut shows also an 
appliance for preventing or 
for correcting slight degrees 
of adduction, while the 
brace is in use as a walking 
appliance. The abduction 
bar is buckled about the 
upper extremity of the other 
thigh. (H. L. Taylor, Med. 
News, March 23, 1889.) 



Taylor's median abduction brace used as a bed splint to overcome 
adduction by counter-pressure on the sound side. 



that have been described. If the disease be acute, recumbency and 
traction are employed until this stage is passed. 

When ambulation is resumed crutches may be employed for a time, 
but during the greater part of the treatment the brace is used as a 
walking appliance ; as accurate splinting and as effective traction being 
employed during this period as circumstances will permit. 



280 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



Fig. 203. 



During the entire course of treatment, supervision of the patient, 
with the aim of adapting his activity to the local weakness, should be 
exercised, even though it may be less essential than when other appa- 
ratus is employed. 

The impression that one might receive 
from descriptions of the treatment of hip 
disease, is that most cases begin acutely, 
or that when the patients are brought for 
treatment the disease is in an acute stage, 
or that deformity is present, so that pre- 
liminary recumbency is required. But 
each year the proportion of early cases is 
greater, cases in which there is no defor- 
mity and in which acute symptoms are 
absent. In such instan- 
Fig. 204. ces the hip splint may be 
applied without prelimi- 
nary recumbency, and if 
the joint is fixed in the 
normal attitude and pro- 
tected, a relatively rapid 
recovery without defor- 
mity and with a fair range 
of motion may be hoped 
for. 

The Treatment of Hip 
Disease During the Stage 
of Recovery. — It is much 
easier to assure oneself 
that the disease is still 
active than to decide 
when it is cured. For 
the symptoms may have 
been quiescent for 
months or years even, 
under the protective 
treatment, and yet they 
may recur on the slight- 
est provocation when this 
treatment has been dis- 
continued. 

To judge of the prob- 
able duration of the dis- 
ease in a given case, one 
must consider its area, its quality and its complications. If, for example, 
the primary symptoms indicate that it is a limited focus of infection 
contained within the bone, rapid recovery, possibly in a year, may 
be expected ; but in the ordinary type of disease in which the joint 




J 



Modified brace to be worn during 
convalescence. Same patient as in 
Fig. 198. The thoracic part has been 
removed aud the lower end of the 
stem has been made into a caliper, 
passing through the heel of the shoe. 
The stem is extended by means of the 
key until the heel is lifted slightly 
from the shoe, thus the hip is relieved 
from shock. 



Judson's perineal 
crutch. This support 
suspended from the 
shoulders may be 
employed as a sub- 
stitute for axillary 
crutches. It is also 
used as a convales- 
cent splint in the 
treatment of hip dis- 
ease. 



TREATMENT DURING CONVALESCENCE IN HIP DISEASE. 281 



Fig. 205. 



has been invaded, repair can hardly be anticipated in less than three 
or four years. 

Supposing the time to have elapsed in which a natural cure may 
have been accomplished ; if the patient has had no symptoms of disease 
for a year or more ; if there are no local signs of active disease, and 
if muscular spasm is absent, one may test the joint by removing the 
brace at night to ascertain the effect of simple motion without weight 
bearing. Such freedom will enable the patient to move the knee, 
which having been fixed in the extended position for so long usually 

remains stiff for a time, and in many in- 
stances several months may elapse before 
the full range of motion is regained. 

It is well also to remove the thoracic part 
of the brace, to allow the patient more mo- 
bility at the hip. At a later time the trac- 
tion may be discontinued and the brace may 
be suspended from the shoulders to serve as a 
perineal crutch (Fig. 204) ; or it may be at- 
tached to the shoe and so adjusted as to be 
slightly longer than the limb, in order that 
direct concussion and pressure may be les- 
sened. (Fig. 203.) Or a brace jointed at the 
C'^ ° l°k$] knee, after the Taylor pattern may be em- 




Fig. 206. 



This brace is so adjusted 
as to be slightly longer than 
the leg, so that the heel does 
not touch the bottom of the 
shoe. (Fig. 206.) Thus the 
weight is in great part sup- 
ported on the perineal band. 
The weight of the brace* may 
be in part supported and 
incidentally slight traction 
may be exerted by adhesive 
plaster applied above the 
knee. (Fig. 207.) The foot 
plate to which the upright 
is attached is shown in Figs. 
206 and 208. 

As the strain upon the 
part is increased, one 
watches carefully for the 
return of muscular spasm 
or for restriction of the range of motion. If the range of motion does 
not diminish, and if the deformity that may be present does not in- 
crease or does not appear if it be absent, the brace may be removed at 
intervals and finally discarded. 




Convalescent hip splint, allowing motion at the knee. 
(Taylor.) 



282 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



This stage of supervision even in favorable cases should be protracted, 
for no patient can be considered free from the danger of relapse for a 
long time after apparent cure. If there be firm bony anchylosis, as in 
exceptional cases, cure is assured ; but if there be simply fibrous anchy- 
losis, and particularly if there be upward displacement of the trochanter, 
a tendency to deformity remains, particularly toward flexion and ad- 
duction, even though the disease is cured. In such cases it is often 



Fig. 207. 



Fig. 208. 



Fig. 209. 





Details of the Taylor convalescent hip brace. Fig. 
207, the adhesive plaster. Fig. 208, the foot plate show- 
ing the method of attachment. 



The action of the Taylor convales- 
cent hip brace in removing direct 
pressure illustrated by a wooden 
model. 



necessary to employ apparatus at intervals to reduce the deformity or to 
hold the limb in proper position until stability is assured. When the 
brace has been discarded, the patient should be trained to walk with 
equal steps, placing the limb, as far as is possible, on an equality with 
its fellow and adapting in like manner the stronger to the weaker 
member. This has an important influence in checking the tendency to 



DOUBLE HIP DISEASE. 



283 



deformity and in modifying, or even concealing, the limp, a point to 
which Judson has repeatedly called attention. 



Fig. 210. 




Double hip disease terminating in bony anchylosis. 



Double Hip Disease. 



Ninety-five cases of bilateral hip disease were treated in the Hospital 
for Ruptured and Crippled during the ten years ending in 1899. . 

As a rule the second hip is affected some time after the symptoms of 
disease of the first have been apparent, but occasionally both joints are 



Fig. 211. 




Left hip disease, showing swelling caused by abscess, also tbe absence of flexion deformity 



284 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



Fig. 212. 



involved simultaneously. In most instances the symptoms are rather 
subacute, owing, very likely, to the fact that the activity of the patient 
is so restricted. 

Treatment. — The treatment is similar in principle to that of the 
unilateral form. The patient during the greater part of the course of 
the disease must be confined in the recumbent position, although not 

necessarily in bed. The double 
Thomas hip splint is a convenient 
means of fixation. With this appa- 
ratus, extension by means of the 
weight and pulley may be employed, 
or the brace may be so modified as to 
provide independent traction . If the 
disease of one hip is acute and is at- 
tended by abscess formation, excision 
for the purpose of lessening the strain 
upon the patient and assuring a cer- 
tain amount of motion in one limb 
may be advisable. 

If motion is greatly restricted in 
both joints locomotion unless 
crutches are used, is very difficult, as 
motion at the knees can supply only 
in small part the function of the hip 
joints. 

Hip Disease Combined with Disease 
of Other Parts. 



The most common combination is 
with Pott's disease. The two may be 
distinct primary foci, but occasionally 
it would appear that the disease of the 
hip is caused by the infection of an 
abscess, which, coming from the spine, 
remains for a long time in contact with 
the capsule of the joint. In five of the 
one hundred and fifty cases of disease 
of the hip joint of which J;he final re- 
sults are reported by Gibney, Water- 
man and Reynolds (page 298), Pott's 
disease was a complication ; in two 
instances preceding, and in three fol- 
The combination of the two diseases 
Recumbency offers the 




Untreated hip disease. Slight flexion 
and adduction (apparent shortening). 
The scar of a former abscess is seen on 
the outer aspect of the thigh. 



lowing, the disease at the hip. 

makes the mechanical treatment difficult, 

best opportunity for the effective adjustment of apparatus when the 

disease of either part is acute. At a later period crutches may be 

employed, together with the necessary braces. 



HIP DISEASE IN THE ADULT. 285 

Hip Disease in Infancy. 

Hip disease in infancy is far less common than in early childhood. 
It presents nothing of especial interest except that its effect upon the 
function of the joint and upon the development of the limb is usually 
more marked than in older subjects. (Fig. 184.) Tuberculous disease 
of this joint must be differentiated from infectious epiphysitis, in 
which prompt operative treatment is indicated. 

Hip Disease in the Adult. 

Hip disease in the adult may present the typical symptoms of the 
ordinary form, but it is usually of the more subacute type. Not infre- 
quently it is a complication of tuberculosis of the lungs. The mechan- 
ical treatment is not difficult, but, in many instances, early excision may 
be advisable in order to bring about a rapid cure of the disease. This 
is far more important than in childhood, because few adults can afford 
the time required for the natural cure, and because in many instances, 
the general condition of the patient may demand relief from the de- 
pressing effects of the local disease, especially if it be complicated by 
suppuration. 

The subacute form of tuberculous disease is often difficult to dis- 
tinguish from arthritis deformans, if this be confined to the hip joint. 

Abscess in Hip Disease. 

It may be assumed that a limited collection of fluid product of the 
tuberculous process is present in nearly every case of hip disease in 
which the joint surfaces are actually involved. In many instances it 
remains within the joint. In a larger proportion of the cases the cap- 
sule is perforated, the fluid escapes and, if the quantity is sufficient to 
form an appreciable tumor, it is classed as an abscess. Such abscesses 
may be detected in about 50 per cent, of the cases that are treated 
under ordinary conditions. 

In eight hundred and two final results collected from various sources, 
the percentage of abscess was as appears in the following table : 

39 cases reported by Shaffer and Lovett 1 69 per cent. 

82 cases reported by Gibney 2 60 " 

390 cases reported by Brims, 3 Tubingen 58 3 " 

125 cases reported by Sasse, 4 Berlin 50 " 

82 cases reported by Prendlsberger, 5 Vienna.. 51 " 

84 cases in private practice, C. F. Taylor 6 25 " 

Most often the abscess first appears upon the outer and upper part of 
the thigh, in the space between the sartorius and tensor vagina? femoris 

1 N. Y. Med. Journal, May 21, 1887. 
2 N. Y. Med. Kecord, March 2, 1878. 

3 Beit, zurklin. Chir., Bd. 30, 1895. 

4 Arbeit aus der Chir. Klinik der K. Univ. Berlin (Bergmann's Clinic), 1896. 

5 Behand der Gelenktuberculose und ihre Endresultate aus der Klinik Albert, Wien, 
1894. 

6 Boston Med. and Surg. Jour., March 6, 1879. 



286 



TUBERCULOUS DISEASE OF THE HIP JOINT. 



muscles. From this point it may find its way to the inner or to the 
posterior surface of the limb, and if it increases in size it gradually 
sinks downward, guided somewhat in its direction by the layers of 
fascia that separate the muscles. In other instances it may be de- 
tected first on the inner side of the thigh, or it may form a tumor be- 
neath the gluteal muscles ; its situation being influenced by the point 
at which the capsule is ruptured. In rare instances, the acetabulum 
may be perforated and a pelvic abscess may be formed, or the pus may 
find its way into the pelvis along the course of the ilio-psoas muscle ; 
and occasionally a pelvic abscess may exist which appears to have no 
direct communication with the joint. 

The tuberculous abscess is a symptom and common accompaniment 
of hip disease, which, in cases treated under proper conditions, is not of 
great importance ; and yet on the other hand, it is recognized as a dan- 
gerous complication. It is dangerous to life because of the profuse 
suppuration that may follow infection, and to function because of the 



Fig. 213. 




Abscess in hip disease. The brace is provided with the Thomas ring and with the ratchet extension. 

adhesions and contractions that may result. This is evident in all 
statistics. It is clearly shown in those of Bruns. In this list the 
mortality in the non-suppurative cases was 23 per cent, and of the 
suppurative 52 per cent. 

The Significance of Abscess. — If abscess appears early in the course 
of the disease, it usually indicates that it is of a destructive character 
and that the interior of the joint is involved, therefore perfect function 
is less likely to be preserved than in those cases in which the disease 
has been confined to the interior of the bone. 

In certain instances abscess formation is preceded by an acute ex- 
acerbation of symptoms, by pain, by an increase of muscular spasm 
and consequent distortion, and often by an elevation of temperature. 
These acute symptoms subside and a fluctuating swelling appears. It 
may be inferred that the pain in such a case was due to the tension of 
the abscess within the capsule, and that the relief of pain followed 
perforation and the escape of the fluid. 



TREATMENT OF ABSCESS. 287 

In perhaps the larger proportion of cases, more especially those in 
which the joint has been protected, the formation of the abscess is 
not preceded by acute symptoms, such as have been described. Its 
appearance is long delayed, and but for the swelling that is apparent, 
its presence would not have been suspected. 

As the progress of the disease is influenced by the strain and in- 
jury to w 7 hich the part is subjected, so abscess, a symptom of disease, 
is more common in those cases in which early and efficient treatment 
has been neglected ; for the same reason its subsequent course is directly 
influenced by the protection that the diseased joint receives. 

The danger from abscess is, of course, infection. Occasionally the 
abscess may become infected before an opening forms. Such infection 
may be inferred when the tissues about the abscess are hot and sensi- 
tive, and when fever is present ; but as a rule, the abscess is sterile 
until the skin is perforated. When an opening forms there is danger 
of infection with pyogenic germs. If the abscess sac is small and if 
drainage is efficient, and especially if the communication with the joint 
has been occluded, infection is of slight consequence. But if before 
the opening has formed the abscess has perforated inter-muscular fas- 
cia and has extended between the layers of muscles in various direc- 
tions, the infection of this area is likely to cause severe local and con- 
stitutional symptoms. The thigh becomes the seat of an infectious 
cellulitis, pockets of pus form, which cannot be properly drained ; 
hectic, emaciation and loss of appetite follow, and if the profuse dis- 
charge of pus persists, amyloid degeneration of the internal organs may 
result. Such patients are said to die of exhaustion, but the cause of 
the exhaustion is an infected abscess. At this stage the operation of 
excision of the joint is often performed. This operation removes the 
original source of the trouble, but the success of the procedure depends, 
in most instances, upon the efficiency of the drainage that is assured by 
the wide, deep incision and by the removal of the obstructing head of the 
bone. Thus when suppuration persists after excision and when th'e con- 
dition of the patient is not improved, amputation is logically indicated. 

Treatment. — Admitting that abscess is a symptom whose importance 
stands in direct relation to the care that has been exercised in the treat- 
ment of the disease, and that in the better class of cases the danger from 
this source is slight, still it is also true that abscess is the chief cause of 
danger, and almost the only cause of death, in hip disease per se. One's 
views as to treatment are likely to be influenced by the class of cases 
with which he is most familiar. Some surgeons have advocated abso- 
lute non-interference with the symptomatic abscess on the ground that 
in many instances it finally disappears by spontaneous absorption ; 
while in other cases the long delay allows the communication with the 
joint to close, so that the danger of infection after an opening has 
formed, is slight. Finally, that the results after non-interference are 
better than those reported after operative treatment. Others insist 
that all collections of fluid of this character should be evacuated when 
they are discovered, because of the danger of infection before an open- 



288 TUBERCULOUS DISEASE OF THE HIP JOINT. 

ing forms and because of the advantage gained by preventing burrow- 
ing of pus. There would be little to be said against this latter course 
were it not that infection is as common after operative treatment as 
when a spontaneous opening forms ; the only advantage in favor of 
the artificial opening being that the cavity with which it communicates 
should be smaller than when the incision has been long delayed ; but 
this is offset by the fact that at least 20 per cent, of abscesses disap- 
pear without treatment. In fact, as compared with indiscriminate 
incisions, when proper precaution and care cannot be assured, the let- 
alone treatment should be preferred. 

It would appear, however, that the middle course, between the ex- 
tremes, is the safest, and especially so as by far the larger number of 
patients must be treated under conditions that do not permit of proper 
care. In the outdoor department of the Hospital for Ruptured and 
Crippled abscesses are treated symptomatically. If a swelling appears 
but remains quiescent and causes no symptoms, it is not disturbed. If 
it enlarges, the tension of the fluid is relieved by aspiration, which 
may be repeated as required, compression, after the evacuation of the 
fluid, being applied by a pad and bandage. If the abscess is on the 
point of finding a spontaneous opening, or if its contents are of such a 
nature that aspiration is impossible, an incision is made and the proper 
dressings are applied ; or, if the child lives at a distance from the hos- 
pital, the mother is instructed in the manner of dressing and as to the 
importance of cleanliness. 

If the abscess is of large size, or if acute symptoms are present, the 
child is admitted to the hospital. Here the same general principle is 
followed, but at the present time the routine of treatment of non-in- 
fected abscess is free incision, that will allow complete evacuation of 
its contents. The abscess membrane is removed by gently rubbing 
with iodoformized gauze. If the opening in the capsule of the joint is 
exposed, this may be enlarged to permit of the evacuation of the prod- 
ucts of disease within the joint, the wound is then closed with super- 
ficial and deep sutures, and a firm dressing is applied. This operation, 
if performed under aseptic precautions, causes no disturbance and it 
relieves nature from the burden of necrotic material which must be an 
obstacle to spontaneous absorption. In many instances the abscess is 
permanently cured, although if the condition that induced the ab- 
scess remains unchanged, fluid will again accumulate, and if so a spon- 
taneous opening will form at the site of the operation. This operation 
is not a radical cure of the abscess or of the disease, it is simply a 
means of thorough evacuation for the purpose of accomplishing what 
the aspirator does only in part. If the abscess has become infected, 
its contents are completely removed, the wound is then packed with 
gauze and provision is made for efficient drainage. 

In the treatment of abscesses the injection of iodoform emulsion, in 
connection with the aspiration, has been thoroughly tested. The re- 
sults, as far as the disappearance of the abscess was concerned, were 
not as good as from simple aspiration ; and as the procedure, being 



EXPLORATORY OPERATIONS. 289 

somewhat of the nature of an operation, caused the patients some dis- 
comfort and anxiety, it was discontinued. From the clinical stand- 
point there is little evidence that these injections exercise any particular 
influence upon the disease, but theoretically, iodoform should lessen 
the infectiousness of the tuberculous fluid, and there appears to be no 
serious objection to its use. 

The Treatment of Sinuses. — When the disease is in the active 
stage the sinuses that serve as drains should not be interfered with. 
And in the advanced cases when the disease is quiescent and when the 
tissues about the joint are of the peculiar, resistant, " porky " con- 
sistency, active measures, either for the purpose of closing sinuses, or 
for the correction of deformity, should be deferred. In many in- 
stances, however, sinuses persist as tuberculous fistulse, serving no use- 
ful purpose. In this class the complete removal of the infected tissue 
by excision, or by thorough curetting, is the most effective remedy. 
The various applications of pure carbolic acid, solution of salicylic 
acid, iodoform emulsion, balsam of Peru and the like, are of some ser- 
vice, but thorough removal of the disease is the only radical treatment. 

Exploratory Operations. — In certain instances exploratory opera- 
tions may be indicated. When, for example, the pain and swelling in- 
dicate tension within the capsule, this may be relieved by an incision 
and the joint may be explored with the possibility of finding a local- 
ized focus of disease that may be removed. 

The joint may be exposed by an antero-lateral incision, beginning 
one inch to the outer side of the anterior superior spine and extending 
downward about three inches. This exposes the line of junction be- 
tween the tensor vaginae fern oris and the gluteus medius muscles. 
When these are separated from one another the anterior surface of the 
capsule of the joint is exposed. If more room is required the tensor 
vaginae femoris muscle may be divided. The capsule is then incised 
in the line of the neck and through the incision the head of the bone 
may be extruded by rotating the limb outward and extending it.' By 
this means the character of the disease may be ascertained and in cer- 
tain instances localized foci in the neck or in the head of the bone may 
be removed. Thus the course of the disease may be shortened and 
cure even may be accomplished, as in two cases reported by Blood- 
good. 1 Such an outcome is however most unusual. 

Exploratory operations of this nature may be of especial value in 
the later stages of the disease, to ascertain the cause of long-continued 
suppuration, or of abnormal delay in repair, which may be due to de- 
tached or adherent fragments of necrosed bone within the joint. This 
point is illustrated by the statistics of sixty-one cases of hip disease 
treated by excision, by Poor. 2 In fifteen of these, loose bone was found 
in the joint, and in seven the head of the bone was detached. 

In ninety-eight cases investigated by Lehman 3 at the Wtirzburg 

1 Bulletin Johns Hopkins Hospital, January, 1900. 
*N. Y. Med. Jour., April 23, 1892. 
3 Inaug. diss. Wurzburg, 1896. 

19 



290 TUBERCULOUS DISEASE OF THE HIP JOINT. 

clinic, sequestra were present in 20.4 per cent, and in 70 per cent, of 
eighty-eight cases treated by Riedel. 1 

An exploration of the joint by one familiar with surgical technique, 
should be free from danger. The wound may be closed or it may be 
drained, according to the indications. The operation is not indicated 
as a routine of practice, nor should it be expected by this means to cut 
short the course of the disease, but in certain instances it may be of 
great value. 

Excision of the Hip. — At the Hospital for Ruptured and Crippled, 
the operation of excision is classed as a treatment of necessity in certain 
cases, usually those in which recovery under conservative treatment 
is considered very doubtful. For example, when there is progressive 
failure in health ; when it is impossible to drain the joint effectively 
after infection ; when there is evidence of extension of the disease to 
the shaft of the femur or to the pelvic cavity, or when other serious 
complications exist. 

In certain instances the excision may follow an exploratory opera- 
tion ; in such cases the antero-lateral incision may be employed and 
the neck and head of the bone only may be removed. But in typical 
cases the operation is performed because of extensive disease and in- 
fected abscess, and in such instances the entire upper extremity of the 
bone to the trochanter minor is removed, ordinarily by a posterior 
incision, similar to that of Sayre. The knife entered above and in 
front of the trochanter is carried through the tissues close to its upper 
margin and the incision is prolonged down the posterior border of 
the femur to the trochanter minor. In certain instances an attempt is 
made to preserve the periosteum and the muscular attachments, but in 
the majority of the advanced cases, the soft parts are cut away as 
quickly as possible and the femur is divided with a chisel at the level 
of the trochanter minor. As much of the diseased tissue as is possible 
is cut away and the wound, together with the connecting suppurating 
tracts is packed with gauze. If the shaft of the femur is diseased its 
contents are removed and a counter opening for drainage is made. The 
operation is performed as quickly as possible and a very small amount 
of anaesthetic in employed, nitrous oxide gas having been used in many 
instances. The limb is supported by a plaster bandage or Thomas brace, 
and afterwards a hip splint is used for a time to prevent deformity. 

The functional results after excision in this class of cases are not as 
good as those that are obtained when the operation has been performed 
at an earlier stage. If motion continues free, the joint is usually in- 
secure. In many instances there is upward displacement of the shaft 
of the femur upon the ilium with consequent flexion and adduction de- 
formity, while in a third class of cases a movable joint of sufficient 
strength may be preserved. The ultimate shortening is considerably 
greater than after conservative treatment. This is accounted for by 
the upward displacement of the femur and by the removal of the two 
epiphyses of its upper extremity. 

iCentb. f. Chir., 1893, Bd. XX., Nos. 7 and 8. 



EXCISION OF THE HIP. 291 

In the twelve years, 1888 to 1899 inclusive, 149 operations of ex- 
cision were performed at the Hospital for Ruptured and Crippled. 
During this time 1,283 cases of hip disease were treated in the wards 
and 1,870 new cases were recorded in the out-patient department. 
Thus the operation was performed in 11.6 per cent, of those in the 
hospital, but the relative frequency of the operation in the entire num- 
ber of patients under treatment, was considerably less than this. 

One hundred and twenty-one of these operations of excision, or those 
performed prior to 1897, have been carefully analyzed by Townsend. 1 
The 121 operations were performed on 119 patients, in two instances 
both hips having been operated upon. In 113, abscesses or sinuses 
were present, in most instances infected. In 5 cases the spine was in- 
volved as well as the hip ; in 2 instances the knee, in 2 the tarsus, in 3 
the ilium. In 24 cases the anterior incision was employed, in 97 the 
posterior. In 18 instances the acetabulum was seriously diseased and 
in 10 osteomyelitis of the shaft of the femur was present. This indi- 
cates the character of the disease in the cases operated upon. 

In 99 of the 119 cases the later results of the operation were ascer- 
tained. Of these 52 were dead and 47 were living. Of the 52 deaths 
9 w r ere due directly to the operation, shock ; 28 were caused by ex- 
haustion ; 9 by tuberculous meningitis ; 7 by other causes. Thirty- 
seven deaths occurred within six months and 10 others within one 
year of the operation. Of the 47 patients living at the time of the in- 
vestigation 26 were cured. Of the remaining number about one half 
were in poor condition so that recovery could not be expected. It is 
evident that in a large proportion of the cases the operation was 
unsuccessful as a life-saving measure since suppuration persisted. 

The functional results in these cases are shown in the table on the 
following page. 

Lovett 2 has reported the results of 50 excisions in a similar class of 
cases at the Boston Children's Hospital, 1877 to 1895. The number of 
patients actually treated in the wards of the hospital is not stated, but 
1,100 cases were recorded as having been under treatment during this 
time, a percentage of excisions of 4.5 of the total number. In eight of 
the cases osteomyelitis of the femur was present and in 15 the acetabulum 
was perforated. The ultimate mortality was about 50 per cent. 

Poor 3 has reported the results in 65 cases operated upon at St. Mary's 
Hospital, New York, with a final mortality of about 43 per cent. In 
21 cases osteomyelitis of the shaft of the femur was present. In 11 
cases there was perforation of the acetabulum and in 9 of these the 
opening communicated with an intra-pelvic abscess. 

These statistics are quoted to illustrate the relative efficiency of late 
excision. The extent of the lesions in some of the cases shows that 
recovery would have been impossible without operation, and its failure 
to relieve the symptoms in so many instances is sufficient evidence that 
it was postponed too long. Under proper conditions for treatment ex- 

1 Medical News, June 26, 1897. 2 Trans. Am. Ortho. Ass'n, Vol. X. 

3 K Y. Med. Jour., April 23, 1892. 



292 



TUBERCULOUS DISEASE OF THE HIP JOINT 



cision of the hip is almost never required, but in hospital practice it 
would seem that it should be performed oftener and at an earlier stage 
of the disease. 



Table Showing Shortening, Motion, Number of Sinuses Present, 

and Angle of Greatest Extension in 47 Cases 

of Excision. (Townsend.) 



No. 


Time since operation. 


General 
Condition. 


Sinuses 
present. 


Angle 
of greatest 
extension. 


Motion in 
degrees. 


Shortening 
in inches. 


1 


6f years. 


Good 


3 


150 





2J 


2 


6} " 


Fair 


1 


135 





4 


3 


6 " 


Good 





180 


100 


3 


4 


K3 It 
"4 


(< 





180 


35 


3 


5 


5| " 


Faii- 





145 


10 


4 


6 


5* « 


Good 


1 


165 





H 


7 


5 " 







155 


5 


2J 


8 


43 (< 

^4 




3 


160 





2J 


9 


4J " 







160 





2f 


10 


4£ " 







165 





H 


11 


4 " 







150 





1* 


12 


4 " 


Poor 


4 







n 


13 


3* " 


Good 





155 





1* 


14 


3l " 


n 





160 


30 


1 


15 


3 " 


Poor 


1 


165 





3 

4 


16 


2 " 


Faii- 


2 


145 


30 


3. 
4 


17 


2 " 


Good 










18 


2 " 


Faii- 


1 


170 





1 
*> 


19 


9 << 


Good 





150 





3 


20 


If " 


" 





175 




1 

w 


21 


If " 


a 





165 


*30 


I 


22 


H " 


a 





150 





1 


23 


1J " 


a 





150 





n 


24 


1J " 


a 


1 


180 





h 


25 


li " 


Fair 


6 


175 


15 


1 


26 


1 " 


Poor 


2 


165 





2£ 


27 


1 " 


Good 





170 





n 


28 


1 " 


n 





155 , 





1 


29 


1 " 


a 





175 





1 


30 


1 " 


Poor 





180 


10 


H 


31 


11 months. 


it 


3 


170 





1 
4 


32 


10 " 


" 





180 


40 


li 


33 


10 " 


Good 


3 


165 





i 


34 


10 " 


a 





160 





1 


35 


10 " 


11 


1 


165 





1 


36 


10 " 


Poor 


1 


160 





i 


37 


10 " 


Good 


3 


155 


10 


H 


38 


9 " 


" 


1 




., 


1 
2 


39 


9 " 


11 







..... 


i 


40 


9 " 


Poor 


1 


170 




1 



41 


9 " 


Fair 


3 






1 


42 


8 " 


Good 





180 


130 


* 


43 


8 " 


" 





180 




i 


44 


8 " 


Poor 


1 


165 


"lO 


t 


45 


7 " 


n 










46 


7 " 


Good 





180 


10 


li 


47 


7 u 







160 


70 


4 



Amputation. — Amputation at the hip should follow excision when 
suppuration persists and when the condition of the patient does not 
improve, provided the internal organs are not hopelessly diseased.. 



REDUCTION OF FIXED DEFORMITY. 



293 



The operation of amputation after complete excision is a simple pro- 
cedure and it should not be attended with great danger. 

Reduction of Deformity in Resistant Cases. — The various methods of 
reducing deformity during the active stages of the disease have been 
described, and the importance of preventing deformity throughout the 
entire course of treatment has been insisted on. At the present time, 
for one reason or another, deformity from this cause is very common, 
either because its importance is not appreciated or because it is con- 
sidered as a necessary concomitant of the disease, treated by apparatus, 

as it is in the natural cure. At all _ 01 . 

Fig. 214. 
events in many instances it is 

allowed to persist until the ac- 
commodative changes about the 
diseased joint have so fixed the 
limb in the deformed position that 
greater correcting force is re- 
quired than can be applied by the 
weight and pulley or by other 
method of traction. 

In this class of cases, in which 
the muscles are structurally short- 
ened and in part transformed to 
fibrous tissue, and in which the 
anterior wall of the capsule has 
become retracted and it may be 
adherent to the surrounding parts, 
forcible reduction under anaesthe- 
sia, or osteotomy, may be re- 
quired. If the disease is quies- 
cent, or cured; if the head of the 
femur or what remains of it is in 
the normal position, and if a fair 
range of motion remains, grad- 
ual forcible reduction after di- 
vision of the bands of fascia or the 
muscles that hold the limb in the 
deformed position, is advisable. 

A j?j l i« n . i ip •■ Extreme deformity after hip disease. (See Figs. 

Alter reduction Ol the delormity 215,216.) Showing the attitude in standing before 

in one or more sittings, the limb °P eratlon - 

must be fixed in a long spica bandage and held in this position by this 

or other fixative appliance, until the tendency to deformity has been 

overcome. 

This method of reducing deformity of the more or less resistant 
type has been performed in 329 instances at the Hospital for Ruptured 
and Crippled during the past ten years, with but one death ; from fat 
embolism. 

The Correction of Deformity by Femoral Osteotomy. — If the deformity 
is fixed by bony anchylosis or by firm fibrous adhesions within the 




294 TUBERCULOUS DISEASE OF THE HIP JOINT. 

joint, or if it is feared that violence may stimulate dormant disease ; 
or if there is such a degree of upward displacement of the femur upon 
the pelvis that the deformity is likely to recur after replacement, it is 
better to correct the deformity by an osteotomy of the femur. 

The patient having been prepared for operation, is turned upon the 
side and a sandbag is placed between the thighs. A small osteotome 
about the shape of a lead pencil, of which one extremity is flattened to 
a cutting edge (Vance's instrument), is pushed directly through the 
soft parts to the femur at a point about two inches below the apex of 
the trochanter. It is turned until its cutting edge is at a right angle 
to the shaft and it is then driven through the cortical substance of the 
bone. When it has penetrated at one point it is withdrawn, and ad- 
joining portions are cut until about half the circumference is divided, 
when with slight force the bone may be fractured. If the deformity 
is of long standing, division of the contracted tissues in the adductor 
region and below the anterior superior spine, may be required. The 

Fig. 215. 




The favorite attitude in recumbency. (See Fig. 214.) 

limb is then drawn down to complete extension and moderate abduc- 
tion and the body and limb are encased in a plaster of Paris spica 
bandage which should remain in position for several months, although 
the patient may be allowed to bear weight on the limb in a few weeks 
after the operation. 

The advantages of the subcutaneous method are simplicity and free- 
dom from danger. No dressings are required, except a pad of gauze 
over the minute opening, thus the limb may be firmly held by the 
plaster bandage. If there is anchylosis between the femur and the 
pelvis no support will be required after the bone has united, but if 
there is motion in the joint, some fixative appliance should be em- 
ployed for a time, to prevent recurrence of a part of the deformity. 

During the past ten years this operation has been performed 147 
times without a mishap, at the Hospital for Euptured and Crippled. 
It is especially valuable as a means of correction of extreme and dis- 
abling deformity. 

Prognosis. Mortality. — The direct mortality of hip disease 
is due almost entirely to the immediate or remote effects of abscess. 



THE MORTALITY OF HIP DISEASE. 



295 



Fig. 216. 



This is illustrated by the statistics of Brims in which the mortality 
from all causes of the non-suppurative cases was 23 per cent, as com- 
pared with 52 per cent, in those in which suppuration was present. 

The mortality among the patients treated at 
many of the German clinics is much higher than 
in the corresponding class in this country. 

At Tubingen, according to Wagner, 1 it was 
40 per cent. 

At Kiel, according to Mummelthy, it was 
48.59 per cent, in non-operative cases and 
53.96 per cent, in operative cases. 

At Marburg, according to Marsch, it was 35 
per cent, in non-operative cases and 40.4 per 
cent, in operative cases. 

At Heidelberg, according to Huismans, 2 it 
was 46.6 per cent, in non-operative cases and 
58 per cent, in operative cases. 

At Zurich, according to Pedolin, 3 it was 37.7 
per cent, in non-operative cases and 54 per 
cent, in operative cases. 

At Vienna, according to Prendlsburger, 4 it 
was 17 per cent, in all classes. 

In a total of 636 cases treated by conser- 
vative methods by Rabl, 1859 to 1894, defi- 
nite results were ascertained in 519. 5 335 
were hospital cases. Of these 216 were cured, 
64.4 per cent. 70 died, 20.8 per cent., and 
49, 14.4 per cent., were still under treatment. 
184 were treated as out-patients ; of these 132 
were cured, 71.5 per cent.; 35 died, 19.2 per 
cent., and 17, 9.2 per cent., remained under 
treatment. 

In 288 cases treated at the Hospital for 
Ruptured and Crippled, New York, reported 
by Gibney, 6 the death rate was 12.5 per cent. Sl 

In private practice the statistical reports of NEY -> 
final results show the death rate to be extremely small. C. F. Taylor, 7 
94 cases, including 24 in which suppuration was presented, 3 deaths. 
L. A. Sayre, 8 212 cases, 5 deaths. Lorenz, 9 60 cases with 3 deaths. 

In the clinics of this country the death rate has been estimated to 

1 Beit. z. klin. Chir., Bd. 13, 1895. 

2 Quoted by Binder, Zeits. f. Orthop. Chir., Bd. 7, H. 2 and 3, 1889. 
3 Centb. f. Chir., No. 30, July 25, 1896. 

4 Loc. cit. 

5 ZurConserv. Behand. der tuberculosen Knochen und Gelenksleiden, J. Rabl, Leip- 
zig und Wein, 1895. 

6 N. Y. Med. Jour., July-August, 1877. 

7 Boston Med. and Surg." Jour., March 6, 1879. 

8 N. Y. Jour., April 30, 1892. 

9 Wiener Klinik, 10 and 11, 1892. 




After correction by osteotomy 
and division of the contracted tis- 
sues. See Figs. 214, 215. (Gib- 



296 TUBERCULOUS DISEASE OF THE HIP JOINT. 

be from 10 to 15 per cent., a rate of mortality much lower than that 
reported from those abroad. This is accounted for, in part, by the 
fact that patients are of a better class and in part because they receive 
earlier and more efficient mechanical protection. 

The causes of death, according to Wagner's statistics of 124 cases, 
were as follows : 

Hip disease 35 

General tuberculosis 37 

Tuberculous meningitis 13 

Tuberculosis of the lungs 11 

Acute miliary tuberculosis 5 

Amyloid degeneration 8 

Septic infection 12 

Intercurrent disease 3 

124 

Thirty per cent, of the deaths occurred in the first year of the dis- 
ease, 26 per cent, in the second year and 20.4 per cent, in the third year. 

The percentage of recovery was 65 per cent, of those in the first de- 
cade of life, 56 per cent, of those in the second and but 28 per cent, 
of those in the third decade. 

The causes of death in 50 cases among 778 patients treated at the 
N. Y. Orthopaedic Dispensary and Hospital during the years 1877 to 
1882 were: 1 

Tuberculous meningitis 20 

Amyloid degeneration 5 

Exhaustion 3 

Tuberculosis of the lungs 3 

Tuberculous peritonitis 1 

Septicaemia 1 

Convulsions 1 

Unknown 16 

50 

Of 96 deaths recorded at the Alexandra Hospital, London (a mor- 
tality of about 26 per cent, of the cases treated), the causes were 

Tuberculous meningitis 16.7 per cent. 

Albuminuria and dropsy 20.8 " 

Tuberculosis of the lungs 8.3 " 

Exhaustion 9.4 " 

Erysipelas and pyaemia 3.1 _." 

After operation 9.4 

Intercurrent diseases 7.3 u 

Unknown 25.0 " 

100.0 " 

The direct mortality of hip disease should include all deaths due to 
operation, those caused by exhaustion and by amyloid degeneration, 
which is almost always the result of profuse suppuration secondary to 
pyogenic infection. While tuberculous meningitis or other forms of 
tuberculous disease may have been due to new infection or may have 
been caused by infection from the primary focus which preceded the 
1 Shaffer and Lovett, N. Y. Med. Jour., May 21, 1887. 



FUNCTIONAL RESULTS. 297 

tuberculosis of the hip, although exhausting local disease by lowering 
the vital resistance would still be an indirect cause of death. 

It is believed that operative interference is sometimes the direct 
cause of tuberculous meningitis, and it is of interest in this connection 
to note that 20 of 50 deaths, or rather of 34, in which the cause of 
death Avas known, 58 per cent, were due to this complication among 
the cases treated at the New York Orthopaedic Dispensary and Hos- 
pital where no operations were performed. 1 "While of 52 deaths in a 
total of 99 cases treated at the Hospital for Ruptured and Crippled, in 
which excision was performed, but 9 were caused by tuberculous men- 
ingitis. 2 

The normal death rate among cases under fair hygienic conditions 
is illustrated by statistics from the Hospital for Ruptured and Crip- 
pled, at a time when no operative or mechanical treatment was em- 
ployed. 3 This was 12.5 per cent. : 4.5 per cent, from exhaustion, 
4.5 per cent, from amyloid degeneration, 1.75 per cent, from tubercu- 
lous meningitis, 1.75 per cent, from intercurrent diseases. 

Thus nearly 75 per cent, of the deaths were due more or less di- 
rectly to suppuration. 

Functional Results. — In a certain proportion of cases perfect 
function may be retained, the proportion depending upon the extent of 
the disease, and upon the timeliness and efficiency of the treatment. 

In a total of two hundred and eighty cases from the private practice of 
Dr. L. A. Sayre, 4 in which the final results were known, seventy-three or 
26 per cent, recovered with perfect motion, and one hundred and twenty 
or 42 per cent, retained good motion. These results are extraordinarily 
good, very much better than any others that have been reported, and of 
course far better than may be expected in the ordinary class of cases. 

The effect of mechanical treatment and of the various measures em- 
ployed for the correction of deformity is well illustrated in two series 
of ultimate results in cases treated at the Hospital for Ruptured and 
Crippled, reported by Gibney. 5 In the first series of 80 cases no me- 
chanical or operative measures were employed, the treatment being 
simply hygienic and symptomatic ; the results therefore represent nat- 
ural cure under proper supervision. The duration of the disease was 
3 years in twenty- three, 3 to 6 years in twenty-eight, 6 to 10 years in 
sixteen and 15 years in one case. 

In thirty-five cases the shortening was two inches or more, and in 
nearly every case there was more or less deformity, viz. : 

In 2 there was flexion to 90 

In 3 " " 

In 3 " " 

In 19 " " 

In 19 " " 

In 18 " " 

In 11 " " 

1 Shaffer and Lovett, N. Y. Med. Jour., May 21, 1887. 

2 Townsend, Med. News, June 26, 1896. 4 N". Y. Med. Jour., April 30, 1892. 

3 Gibnev, N. Y. Med. Record, March 2, 1878. 5 Loc. cit. 



90 






degrees. 


110 






t i 


120 






a 


135 






n 


145 






u 


150 






a 


160- 


1 


"0 


n 



298 TUBERCULOUS DISEASE OF THE HIP JOINT. 

In 4 no estimate was made. Distortions other than flexion are not 
specified. 

In 12 instances motion was retained of from 15 to 90 degrees. 

In the second series ! of one hundred and seven cured cases, mechanical 
and operative treatment was employed although the protection assured 
was in many instances far from efficient. In many of these cases the 
disease was in an advanced stage, and deformity was present in more 
than half of the number when treatment was begun, and yet all of 
them recovered without marked flexion and presumably without ad- 
duction, as this deformity is not mentioned. 

47 had no flexion. 

30 " flexion to 170 to 180 degrees. 
20 " " 160 " 170 " 

10 " " 150 " 160 " 

Perfect motion was retained in 13. 
Good motion was retained in 22 
Limited motion was retained in 41. 
In 31 there was anchylosis. 

In 69 cases the shortening was one inch or less, 35 having no 
shortening. In 38 it was more than one inch. 

As has been stated, the mechanical treatment was not sufficiently 
effective to prevent deformity and to attain these results osteotomy 
with or without division of contracted tissues was performed in 19 
cases ; forcible correction with or without tenotomy in 30 cases and in 
4 cases the joint was excised. 

If the joint has been actually invaded by disease so that a part of its 
articulating surface has been destroyed, motion must be impeded both 
in area and quality. In such cases the joint is usually somewhat 
weakened although not to the extent of interfering seriously with the 
ability of the patient. In many instances, discomfort in damp weather 
or pain on over-exertion, is experienced, symptoms similar to those 
complained of by rheumatic subjects. 

Simple shortening, due to retardation of growth, unaccompanied by 
deformity, is of comparatively little importance. Anchylosis in a sym- 
metrical position insures a strong and useful limb, the flexibility of the 
lumbar region compensating for the loss of motion at the joint. In 
such cases the disability may be very slight, and the effect of the loss 
of motion may be more apparent in the sitting than in the erect pos- 
ture, for the patient must, as it were, sit upon his back, an attitude 
which perceptibly reduces the sitting height. 

Flexion, if it be slight does not cause disability, but flexion of more 
than 30 degrees increases the lumbar lordosis and makes the buttock 
prominent, the deformity so characteristic of the natural cure. (Fig. 
166.) Great flexion, for example of 60 or 90 degrees, causes an ex- 
aggerated lordosis which is almost always a source of pain or discom- 
fort to a patient who is obliged to stand much of the time. 

Abduction is of no importance unless it be considerable. It serves 
in most instances as a compensation for actual shortening of the limb. 
1 Gibney, Waterman and Reynolds, Trans. Am. Orth. Ass'n, Vol. XL, 1898. 



DEFORMITIES OF OTHER PARTS, CAUSED BY HIP DISEASE. 299 

Adduction, on the other hand, which necessitates an upward tilting 
of the pelvis in order to restore the parallelism of the limbs, is the 
most disastrous of all the distortions since it causes a practical shorten- 
ing often greater than that due to the destructive effects of the disease. 

Deformities of Other Parts, caused by Hip Disease. — De- 
formities of other parts are sometimes observed as secondary results 
of hip disease, n\ost often in cases that have not received proper treat- 
ment. In the spine an exaggerated lordosis as a compensation for 
flexion is not uncommon, and lateral curvature may follow dis- 
tortion of the pelvis caused by adduction. In the limb, knock knee 
may follow persistent adduction of the thigh or it may be an effect 
of laxity of the ligaments, without such distortion. Another defor- 
mity is genu recurvatum. This is apparently caused by long-con- 
tinued disuse of the limb and by the use of apparatus in which the 
knee has not been properly supported. It is supposed to be one of the 
effects of traction, but it is also observed in cases in which traction 
has never been employed. In cases in which the muscular atrophy 
that follows limited motion and long-continued disuse, is great, laxity 
of the ligaments of the knee joint is common. A slight degree of 
equinus with accompanying exaggeration of the arch, is not uncom- 
mon among patients who have been treated by the traction apparatus, 
in which the foot is pendant and in which the toes are often inclined 
downward to guide the brace in walking. Practically speaking, all 
these secondary deformities may be avoided by proper supervision of 
the patient during the period of treatment. 

Asa rule, patients who have recovered from hip disease finally dis- 
card all apparatus, or at most use only a cane as a support, and many 
prefer to walk habitually on the toe rather than to equalize the length 
of the limbs by a high shoe. 

In conclusion it may be stated that by far the larger number of 
this class, having accommodated themselves to whatever weakness and 
distortion may be present are able to undertake the ordinary occupa- 
tions of life. Of the patients cured at the New York Orthopaedic Dis- 
pensary and Hospital in the report already referred to, in whom the 
final results as regards motion and symmetry were certainly not above 
the average, it is stated that there was not a single individual who was 
incapacitated from doing a full day's work at his or her trade or occupa- 
tion. None used crutches and but one used a cane. 



CHAPTER VIII. 
NON-TUBERCULOUS AFFECTIONS OF THE HIP JOINT. 

Traumatisms at the Hip. 

It is probable that injury at the hip joint, caused by falls or strains, 
may induce congestion about the epiphyseal cartilage of the head of the 
femur and consequent discomfort, a variety of the so-called growing 
pain. In this class of cases there may be a limp and restriction of mo- 
tion that may disappear in a few days or that may recur from time to 
time. If the injury is more severe there may be local sensitiveness and 
even swelling — synovitis. This congestion may be a predisposing cause 
of tuberculous disease and it is probable that cases of this type are some- 
times mistaken for hip disease and go to swell the number of perfect 
functional results that are attained by one or another system of treatment. 

Treatment. — All cases of this class require careful treatment and 
supervision. Strains or other injuries, in young children, are best 
treated by a supporting bandage and by rest in bed until the symp- 
toms disappear. If the sensitive condition persists, protective treat- 
ment by a brace, preferably the ordinary traction hip splint, should be 
employed, the diagnosis being reserved until it is made clear by the 
progress of the case. Chronic synovitis of the hip joint, especially in 
the adolescent or adult, unless it be a result of severe injury, is usually 
tuberculous in character. 

Fracture of the neck of the femur in childhood will be considered in 
connection with coxa vara. 

Acute Infectious Arthritis ; Acute Epiphysitis at the Hip. 

Acute epiphysitis, caused by infection with pyogenic germs, is not 
uncommon in infancy and early childhood and it often passes as a form 
of acute tuberculous disease. In fifty-two cases in which but a single 
joint was involved the hip was affected in twenty-six. 1 In some in- 
stances it is caused apparently by injury, in others it is secondary to 
an infected wound and not uncommonly it follows pneumonia or one 
of the exanthemata. (See page 211.) 

Symptoms. — The symptoms are of sudden onset, accompanied usu- 
ally by high fever and prostration. The hip becomes swollen, hot, 
and sensitive both to motion and pressure. 

Treatment. — The treatment is early and free incision and efficieut 

drainage, the limb being afterwards supported by some form of splint. 

The suppuration ordinarily persists for several months ; the epiphysis 

is usually destroyed and in consequence the joint becomes somewhat 

1 Townsend, Am. Jour. Med. Sci., Jan., 1890. 



EX TRA-ARTICULA R DISK A SE. 



301 



loose and flail-like. (Fig. 217.) Many of these cases seen in later 
years, but for the history and the scars about the joint, might be mis- 
taken for congenital dislocation. In certain instances the symptoms 
are less acute and the diagnosis from tuberculous disease can be made 
positively only after a bacteriological examination of the fluid that may 
be removed from the joint by aspiration. 

In the class of cases in which the disease is Fig. '111. 

confined to one joint and in which the shaft of 
the bone is not involved, the prognosis is good 
if the pus is thoroughly evacuated. In twelve 
cases treated at the Hospital for Ruptured and 
Crippled there were three deaths. 1 The prog- 
nosis as to function under these conditions is 
much better than in tuberculous disease. 

After recovery, the joint should be support- 
ed for a time, to prevent upward displacement. 

In the forms of arthritis that may compli- 
cate infectious diseases several joints are 
usually involved and the affection is often 
subacute in character. 

Spontaneous Dislocation of the Hip. 
— If the hip joint becomes distended with 
fluid the capsule may be ruptured and sudden 
displacement may occur. 

Degez, 2 has collected from literature 79 
cases of this character. The displacement oc- 
curred in the course of the following diseases : 

Typhoid fever 32 

Rh eumatism 24 

Scarlatina 13 



Variola 

Gonorrheal arthritis. 

Grippe 

Erysipelas 

Eruptive fever 




The effect of acute epiphysitis 
of the right hip at three months of 
age. The scar is shown. 



Such accidents may be guarded against by 
preventing flexion and adduction of the limb 
and by an evacuation of the fluid that distends 
the joint. The femur may be replaced if an 

opportunity is offered, before it has become fixed by adhesions and con- 
tractions. Once replaced it must be held in proper position for a time, 
by apparatus. 

Extra- Articular Disease. 

Occasionally tuberculous disease, or other form of destructive osti- 
tis, may begin in the neighborhood of the trochanter major. The 
symptoms are local pain, sensitiveness and swelling of the soft parts, 
and thickening and irregularity of the underlying bone. 

1 Townsend, loc. cit. 2 Eevue d'Orthopedie, January 1, 1899. 



302 NON-TUBERCULOUS AFFECTIONS OF THE HIP JOINT. 

The treatment is prompt removal of the focus of disease, before the 
joint or the shaft of the femur has become involved. 

Malignant Disease of the Hip Joint. 

Carcinoma of the upper extremity of the femur is almost always 
secondary to a primary tumor of another part of the body. Sarcoma 
is far less frequent in this situation than at the knee. The character 
of the disease soon becomes evident in the general enlargement of the 
upper extremity of the thigh, but in the early stage diagnosis can be 
made only by means of the X-ray or by exploratory incision. 

Cysts of the Femur. 

In extremely rare instances cysts, caused apparently by inclusion of 
a displaced portion of epiphyseal cartilage, may cause enlargement, 
weakening and deformity of the upper extremity of the femur. In 
one case, treated at the Hospital for Ruptured and Crippled, discom- 
fort, limp and outward bowing of the femur in a boy thirteen years 
of age, was found on examination to be caused by a cyst of this char- 
acter. Relief followed its removal. 

Gluteal Bursitis. — An enlargement of one of the bursas lying 
beneath the gluteal muscles, may cause a rounded, fluctuating swelling 
in the buttock. It may be painful to pressure and it usually causes a 
limp, and some discomfort on motion, dependent upon the degree of 
inflammation that may be present. Occasionally the bursitis may be 
caused by injury, but in most instances it is the result of tuberculous 
infection. The bursa may communicate with a diseased hip joint, but 
usually it is a distinct and primary inflammation. 

Ilio-Psoas Bursitis. — This causes a distinct swelling on the upper 
and inner aspect of the thigh. It is usually accompanied by slight 
flexion, abduction and outward rotation of the limb, an attitude that 
relieves the tension on the sensitive part. Zuelzer has collected from 
literature 45 cases of gluteal and 15 of ilio-psoas bursitis. This illus- 
trates the relative frequency of the two affections. 1 

Simple bursitis may be distinguished from disease of the joint by the 
absence of characteristic muscular spasm and general limitation of 
motion. 

Treatment. — Chronic disease of bursa? is usually tuberculous in 
character, thus radical removal of the sac is advisable. Aspiration and 
injection of carbolic acid or iodoform emulsion may be employed as 
primary measures. 

ARTHRITIS DEFORMANS. 
Osteo -arthritis of the Hip Joint. 

Osteo-arthritis, in certain instances, may be confined to the hip joint. 
In this form it is an affection of adult life or old age. It is character- 

'Deutsch Zeits. f. Chir., Bd. 50, H. 1 and 2. 



ARTHRITIS DEFORMANS. o03 

ized by disappearance of the cartilage covering the head of the femur 
and by an eburnation and progressive destruction, or wearing away, of 
the underlying bone. At the same time there is formation of ecchon- 
droses, about the margin of the femur and the acetabulum, which be- 
come ossified into irregular masses of bone. In the early stage of the 
affection the fluid within the joint may be increased in amount, but 
later it is diminished in quantity and changed in quality as the synovial 
membrane becomes transformed in part to fibrous tissue. (See p. 212.) 

Symptoms. — The early symptoms are neuralgic pain in the limb, 
"sciatic rheumatism" and sensitiveness about the joint so that the 
patient lies habitually on the other side. The movements of the joint 
become somewhat restricted and, in certain instances, creaking sounds 
are apparent to the patient. In the advanced stages of the disease, 
there is marked thickening about the trochanter which is usually dis- 
placed upward, owing to the progressive changes in the head and neck 
of the femur ; and the limb is distorted in flexion and adduction, 
symptoms that, but for the history, might be mistaken for the results 
of fracture of the neck of the femur. While in the earlier period of 
the disease the limp, the pain and restriction of motion with the attend- 
ant atrophy may simulate very closely tuberculous disease of a sub- 
acute type. 

Treatment. — In the class of cases in which the disease is confined 
to a single joint and in which the symptoms are dependent upon the 
destruction of the joint, protective treatment is indicated. 

If deformity be present it should be reduced by traction and rest in 
bed. Afterwards the symptoms may be relieved by the use of a hip 
splint (Fig. 205) that will remove the weight, and limit the range of mo- 
tion somewhat. In most instances such treatment is not feasible, but 
the use of a firm flannel spica bandage, combined Avith the application 
of cautery, from time to time, adds to the comfort of the patient. 



CHAPTER IX. 



TUBERCULOUS DISEASE OF THE KNEE JOINT. 



Fig. 218. 



Synonyms. — White Swelling, Tumor Albus. 

Tuberculous disease of the knee joint is next in frequency and impor- 
tance to that of the hip. It is however far less dangerous to life, and the 
prognosis, as regards function, is much better than in the former affec- 
tion. This is explained by the simplicity of the joint and by its situ- 
ation at a distance from the trunk, at the junction of two levers of 
nearly equal length and size. Thus the problem of treatment, and 

more especially of protection by mechanical 
means, is comparatively simple; consequently 
it is more often applied, and in proportion to 
its efficiency the injury of functional use is les- 
sened and the tendency to deformity is checked. 
Pathology. — The disease may begin in the 
epiphysis of the femur or in that of the tibia, 
occasionally in the patella or in the head of the 
fibula, or primarily in the synovial membrane. 
In 547 cases, 1 about two-thirds of which 
were in adults, treated at Koenig's clinic in 
Gottingen by operative procedures which per- 
mitted inspection of the joint, 281 (51.4 per 
cent.) were apparently examples of primary 
osteal disease ; 266 (48.6 per cent.) were pri- 
marily synovial. The focus was in the femur 
in 93 instances (33.1 per cent.), in the tibia 
in 107 (38.1 per cent.), in the patella in 33 
(11.7 per cent.), and in more than one bone in 
48 (17.1 per cent.). 

The examination of a joint permitted by 
arthrectomy or excision, can not be sufficiently thorough to exclude 
disease of the bone and to establish the diagnosis of primary disease 
of the synovial membrane, but in 92 instances the opportunity was 
offered by amputation at the thigh, eighty of the patients being adults. 
This examination, presumably thorough, showed the primary disease 
to be of the bone in 50 cases, while in 35 the synovial membrane was 
apparently the seat of the primary affection. 

In 17 of the 50 cases in which the disease was osteal, the focus was 
in the femur ; in 7 it was in the internal condyle, in 6 in the external 










Sectiouofthe knee joint at 
the age of seven years, showing 
the epiphyses of the femur and 
tibia and their relation to the 
capsule. (Kkause.) 



Die Specielle Tuberculose cler Knocken und Geleke, Berlin, 1896. 



STATISTICS. 305 

condyle and it was in other situations in 4 cases. In 17 the primary 
disease was of the tibia ; in 5 of the internal tuberosity, in 5 of the ex- 
ternal tuberosity, in other situations 7. In 5 instances the primary 
disease was of the patella, and more than one bone was involved in 
1 1 cases. Xichols ' states that he has examined 120 tuberculous joints 
of adults and children, after excision, amputation and at autopsy, and 
in every instance primary foci in the bone were discovered. He be- 
lieves primary disease of the synovial membrane to be very uncommon 
and asserts that examinations are of no particular value as establishing 
the absence of primary osteal disease unless the bones are sawed into 
thin sections. This is the view generally held in this country, that in 
the great majority of cases the disease of the bone precedes the disease 
in the interior of the joint. From the clinical standpoint, however, 
one recognizes two distinct types of tuberculous disease : one, beginning 
as a chronic synovitis in which the early symptoms are subacute, a type 
more often seen in adults (Fig. 220) ; and the more common class, in 
which the symptoms of pain, muscular spasm and deformity, seem to 
indicate clearly a primary disease of the bone. 

The proximity of the active disease in the neighborhood of the joint 
sets up a sympathetic hyperemia within it, and an accompanying 
synovitis. If the disease is progressive the synovial membrane be- 
comes thickened and adhesions form between its folds that gradually 
lessen the capacity of the joint and diminish its mobility. When per- 
foration takes places the granulation tissue spreads over the surface of 
the cartilages destroying them in its progress and eroding the under- 
lying bone ; or if the joint is filled with tuberculous pus they may be 
macerated and separated in necrotic shreds. The direct destructive 
effects of the disease are increased by pressure and friction when 
the part is not protected by mechanical means. The hypertrophied 
synovial membrane and the thickened and diseased capsule cause the 
peculiar elastic resistance on palpation, called pseudo-fluctuation. 
In more advanced cases there is also a reactive inflammation in the 
over-lying tissues, accompanied by a formation of fibrous tissue that 
involves the tendons and muscles. These changes within and with- 
out the joint cause the firm resistant tumor characteristic of " white 
swelling." 

Etiology. — The etiology of tuberculous disease has been discussed in 
Chapters V. and VII. 

Statistics. — Tuberculosis of the knee-joint is essentially a disease of 
early life although it is less strictly confined to childhood than is dis- 
ease of the spine or hip. Sex exercises but little influence and the two 
sides are affected in nearly equal numbers. These points are illustrated 
by the following table of 1,000 consecutive cases treated at the Hos- 
pital for Ruptured and Crippled. 2 

1 Trans. Am. Orth. Ass'n, Vol. XI. 

2 These statistics, together with those of tuberculous disease of the joints, other than 
of the hip, were collected for me by Drs. F. C. Bradner, S. E. Sprague, E. L. Barnett, 
and S. W. Stone, House officers at the Hospital, 1900-1901. 

20 



306 TUBERCULOUS DISEASE OF THE KNEE JOINT 



Age at Incipiency of Knee Joint Disease. 

1 year or less 25 22 years old 13 

2 years old 45 23 



3 


a 


i i 


4 


(( 


ii 


5 


it 


ii 


6 


i i 


ii 


7 


a 


ii 


8 


a 


a 


9 


i i 


a 


10 


ii 


a 


11 


a 


a 


12 


a 


a 


13 


a 


a 


14 


a 


i i 


15 


i c 


a 


16 


i i 


a 


17 


a 


a 


18 


a 


a 


19 


ii 


a 


20 


ii 


a 


21 


ii 


a 



. 91 24 

.164 25 

. 84 26 

. 75 27 

. 66 28 

. 74 29 

. 65 30 

. 60 31 

46 32 

20 33 

19 34 
17 35 
12 36 
10 37 

20 38 
8 39 
8 40 
8 41 

12 50 



ii 


12 


a 


8 


a 


3 


a 


2 


i i 


4 


a 


5 


a 


7 


a 


1 


i i 


1 


a 


2 


a 


1 


" 


a 


4 


" 


a 


2 


ii 


1 


a 


1 


a 


1 


" .. 


a 


1 







Males 512— Females 488. Eight 485— Left 515. 

Symptoms. — The general characteristics of tuberculosis have been 
described in the chapters on Pott's disease and hip disease. In the 
description of these affections, however, but little stress was laid on 
local sensitiveness and local swelling because in these situations the dis- 
eased parts lie at a distance from the surface and are concealed by the 
muscles and other tissues. At the knee, on the other hand, the joint 
is superficial, and even slight effusion into the capsule changes, to a 
perceptible degree, its contour, while sensitiveness to pressure, eleva- 
tion of the local temperature and thickening of the tissues are usually 
present. 

Even when the patients are seen at a comparatively early stage of 
the disease, as regards the physical condition of. the joint, the history 
of the affection will almost always show that it is chronic and progres- 
sive in character. The importance of establishing this fact has been 
mentioned in the consideration of hip disease, and it may be stated 
again that a chronic painful disease of a joint, accompanied by a ten- 
dency to deformity, is, in childhood, almost always tuberculous in 
character. 

The symptoms of tuberculous disease may be classified as limp, pain, 
local heat, sensitiveness and swelling, muscular spasm and limitation of 
motion, distortion and atrophy. 

On physical examination one will note the character of the limp, and 
the slight flexion of the limb which usually accompanies it. The joint 
is, as a rule, somewhat enlarged, and the normal depressions about the 
patella and the projection of the component bones, are less accentuated 
than on the opposite side. There is usually slight local elevation of 



SYMPTOMS. 



307 



temperature and sensitiveness to pressure, varying in degree with the 
character of the disease. In certain cases a degree of effusion is present, 
sufficient to cause the symptoms of synovitis, but in most instances the 
swelling is due, in great part, to the hyperemia and thickening of the 
synovial membrane and the capsule, which gives the sensation of elastic 
resistance rather than actual fluctuation. 

The most important sign is limitation of the range of motion caused 
by muscular spasm. The normal range is from complete extension, 180 
degrees, to a degree of flexion, 

limited only by the apposition Fig. 219. 

of the calf and the posterior 
surface of the thigh. Even in 
the early stage of disease, a 
slight limitation of complete 
extension is present, due to re- 
flex muscular spasm, and usu- 
ally a corresponding limitation 
of the complete flexion ; on 
sudden movements, the char- 
acteristic reflex contraction of 
the muscles is apparent. In 
most cases this limitation of 
motion and consequent flexion 
deformity, is well marked on 
the first examination. Atrophy 
of the muscles of the thigh and 
calf, dependent upon the dura- 
tion of the disease and upon 
the interference with function, 
is present, and this atrophy is 
more noticeable because of the 
enlargement of the knee. 

In certain cases, more often 
seen in infancy and early 
childhood, the symptoms are 
more acute and the progress 
of the disease is more rapid, so 
that it may simulate an infec- 
tious epiphysitis. (Fig. 219.) 

In another type, which is more common in adults, the early symp- 
toms are very similar to those of simple chronic synovitis. The joint 
is swollen by a distension of the capsule, pain is not marked and mus- 
cular spasm and limitation of motion are evident only after a careful 
examination. In this class months or years may pass before the 
symptoms become as disabling as when they are characteristic of the 
osteal type of the disease. 

Primary and Secondary Distortions of Knee Joint Disease. 
— At the hip joint, in which the range of motion is extensive, the de- 




Acute tuberculous arthritis of the knee. 



308 



TUBERCULOUS DISEASE OF THE KNEE JOINT. 



Fig. 220. 



formities resulting from disease are somewhat complex, causing, for 
example, apparent shortening or lengthening, according as the limb is 
adducted or abducted. But the movements that the knee joint permits 
are much simpler, and the primary distortion is simply flexion. Com- 
plete extension of the limb, the limit of normal motion in that direction, 
brings the joint surfaces into close apposition ; the ligaments are then 
tense and no lateral motion is permitted. This is the attitude in which 
the greatest efficiency of the limb for weight-bearing, is assured. "When 
the ability of the knee for carrying out its normal Aveight-bearing func- 
tion is lessened by disease which makes the parts sensitive to pressure 

and to strain, the range of extreme mo- 
tion in both extension and flexion is 
lessened and the limb is persistently 
held in flexion to a greater or less degree, 
dependent upon the sensitiveness of the 
joint. The agents that adapt the limb 
to the habitual attitudes are the mus- 
cles under the control of the nervous 
system. In this sense the primary dis- 
tortions are due to muscular action, but 
it is certainly not true that these muscles 
antagonize one another, and that the 
stronger overcoming the weaker cause 
the deformity, since the extensors at this 
joint are stronger than the flexors, and 
since flexion is the primary deformity at 
every joint which is diseased without 
regard to the relative strength of the 
opposing muscular groups. 

In disease at the knee joint, as at other 
joints, the extremes of motion in every 
direction that the joint permits are limited 
by muscular spasm, but limitation of 
extension, which is so essential to nor- 
mal use, is at once evident, while limita- 
tion of flexion, the extremes of which 
are unessential, is only apparent on ex- 
amination. Flexion is then the primary 
distortion at the knee, and other deformities may be classed as secondary. 
Secondary Deformities. — Of these the most common is outward 
rotation of the tibia upon the femur. When the limb is fully extended 
there is no lateral motion at the knee, but when it is flexed lateral 
motion is possible, and in the attitude of flexion the traction of the 
biceps upon the head of the fibula tends to rotate it upon the femur. 
This deformity is also favored by the use of the limb in the attitude 
of outward rotation, which is always assumed when the weakness or 
stiffness of the knee joint is present, and by the secondary knock knee 
that often accompanies the disease. 




Tuberculous disease of the knee in an 
adult. The synovial type. 






SYMPTOMS. 



309 



Subluxation or backward displacement of the tibia upon the femur, 
is another secondary deformity. When the leg is flexed upon the thigh 
the articulating surface of the tibia glides backward upon the condyles 
of the femur. Here it becomes fixed by muscular contraction, and later, 
by the secondary changes within the joint. If muscular spasm be ex- 
treme, this alone might 

cause the subluxation, but Fig. 221. 

there are other factors; one 
is the destructive action of 
the disease which is usually 
most marked at the point 
at which the bones are in 
contact, and the other is the 
leverage exerted upon the 
leg. This is exemplified 
by the increase of the dis- 
placement that is often 
observed when an attempt 
is made to straighten the 
limb by force, against the 
resistance offered by the 
contracted tissues on the 
flexor aspect. The same 
leverage, in slighter de- 
gree, is exerted when the 
weight of the distorted 
limb is supported on the 
heel in the recumbent pos- 
ture, or when the limb is 
extended in the act of 
walking, or if the upper 
extremity of the tibia is 
not supported during the 
period of treatment by 
apparatus. 

Knock knee (genu val- 
gum) is another secondary 
deformity. This is ex- 
plained in certain instances 
by the hypertrophy of the 
internal condyle caused by 
disease, but it is induced 
more directly by the use of 

the flexed and somewhat disabled limb in the passive attitude of out- 
ward rotation. Genu varum is uncommon and it is usually the result 
of the destruction of a part of the external condyle of the femur or 
of the tibia. 

The character and the relative frequency of the deformities are in- 




Untreated disease of the knee joint illustrating the 
hypertrophy of the condyles of the femur, the subluxation 
and outward rotation of the tibia, the atrophy and the 
characteristic deformity. 



310 TUBERCULOUS DISEASE OF THE KNEE JOINT. 

dicated by the statistics from Koenig's 1 clinic, of 150 cases of knee 
joint disease treated by arthrectomy, 128 of these being in children. 
In 94 cases flexion was present; in 50 from a slight degree to 135 
degrees ; in 16, from 135 degrees to 90; in 28, to a right angle or 
less. Together with the flexion were combined other deformities as 
follows : Genu valgum in 60 cases ; moderate in 42 ; extreme in 1 8. 
Genu varum in 1 case. Subluxation of the tibia in 20 cases. Out- 
ward rotation of the tibia in 10 cases. 

As has been stated, the primary deformity of knee disease is simple 
flexion. If the disease is of an acute type this flexion increases rapidly. 
If it is subacute in character, and especially if the clinical signs indi- 
cate that the disease is primarily of the synovial membrane, the prog- 
ress of the deformity is slow. In ordinary cases the other deformities 
appear at a later time when the disease has reached the destructive 
stage ; and they are most marked in patients who have persistently 
used the deformed limb without protection. 

Actual Shortening and Actual Lengthening. — Retardation 
of growth is of course not an early symptom of disease, in fact actual 
lengthening of the limb, due to the irritative effect of the disease upon 
the epiphyseal cartilage of the femur or of the tibia, is common. This 
lengthening, sometimes to the extent of an inch or even more, may 
persist throughout the entire course of treatment, but after the cure of 
the disease a corresponding retardation of growth that will more than 
equalize the length of the limbs, may be expected. And when the 
disease is of the destructive type, the ultimate shortening may be con- 
siderable, two or more inches is not unusual. 

Leusden, 2 in 33 cases under treatment in the clinic at Gottingen, 
1896-1898, found slight shortening in 2, equality of length in 18, 
lengthening of the femur on the diseased side in 13. 

116 cases of tuberculous disease of the knee were measured by Berry 
and Gibney 3 with reference to this point. In 72 of these there was 
actual lengthening of the femur, from which, it may be inferred that 
in at least 62 per cent, of the cases examined the primary disease was 
of the femur. 

In 17 \ inch. 

" 34 h " 

" 15 f " 

" 6 .1 " 

72 — 62 per cent. 

Diagnosis. — Tuberculous disease is a local destructive process that 
is, as a rule, confined to a single joint. This is an important point in 
the differential diagnosis from general or constitutional affections like 
rheumatism, rheumatoid arthritis and the like, in which several joints 
are involved. The following conditions may be considered. 

Injury of the Knee. — Strains of the knee in childhood are often fol- 
lowed by limp and persistent flexion and pain on motion. In such 

1 Trans. Am. Orth. Ass'n, Vol. XL 2 Deutsche Zeits. f. Chir., Bd. 51, H. 3 and 4. 
3 Am. Jour. Med. Sci., Oct., 1893. 



TREATMENT. 311 

cases the onset is sudden and the symptoms usually disappear quickly 
under treatment. Synovitis of traumatic origin is usually indicative 
of a more severe injury. When synovitis persists, the diagnosis may 
be doubtful because tuberculous infection may have followed the orig- 
inal injury. This emphasizes the importance of the careful treatment 
and continued observation of injuries of this class, especially in weakly 
children. 

Synovitis. — Chronic synovitis of doubtful origin, which shows no 
tendency toward recovery, is usually tuberculous in character. 

Haemophilia. — Effusion of blood into the knee joint may cause in- 
flammatory symptoms during the stage of absorption and organization 
of the clot, that resemble those of disease. The sudden onset and the 
personal history of the patient, who may be known as a bleeder, will 
explain the symptoms. (See page 216.) 

Infectious Arthritis — Acute Epiphysitis. — This is of sudden onset, 
attended by the constitutional and local symptoms of suppuration. 

Rheumatism. — This, in early childhood, may be confined to a single 
joint, but it is of sudden onset and is usually accompanied by consti- 
tutional disturbance, and after a time other joints become involved. 

Rheumatoid Arthritis — Osteo-arthritis. — This affection, of the mon- 
articular form, is a disease of adult life. It is usually characteristically 
" rheumatic " in symptoms. 

Charcot's Disease. — Charcot's disease of the knee joint is characterized 
by sudden effusion, by rapid destruction of the joint and consequently 
by weakness and deformity ; but pain is usually very slight and mus- 
cular spasm is absent. The diagnosis of the disease of the spinal cord 
will explain the condition of the joint. (See page 217.) 

Sarcoma. — Sarcoma, beginning in or near the epiphysis of the femur 
or of the tibia, may simulate tuberculous disease very closely. If the 
tumor is of the periosteal type, it usually forms a more localized and 
irregular swelling than could be accounted for by tuberculous disease. 
Central sarcoma may simulate tuberculosis very closely, but the progress 
of the tumor is more rapid. The clinical distinction between the two 
is that tuberculous disease is very amenable to treatment, as far as its 
symptoms are concerned, while the progress of sarcoma is but little 
influenced by treatment. It may be stated, however, that the X-ray 
is the only means of early diagnosis, as the destruction of the substance 
of the bone about the tumor is much greater than that caused by tuber- 
culous disease. 

Hysterical Joint. — Some of the symptoms of disease may be simu- 
lated by hysterical subjects, but there is always an absence of the 
positive physical signs that invariably accompany a destructive disease. 

Treatment. — The treatment of tuberculous disease of the knee in 
childhood is conservative, operative intervention being simply inciden- 
tal to protective treatment, while in adult life the radical removal of 
the disease may be indicated as the primary measure. 

The reasons for this distinction are obvious. In childhood the 
duration of treatment is of no particular importance as compared with 



312 



TUBERCULOUS DISEASE OF THE KNEE JOINT. 



the final functional result, but in adult life the shortening of the period 
of disability and the definite assurance of cure may be of far greater 
moment than the preservation of motion. 

Under favorable conditions in childhood the prognosis of recovery, 
with fair functional use of the joint, is good ; while a radical operation, 
although it may cure the patient in a shorter time, takes away the pos- 
sibility of a cure with motion. In adult life a rigid limb is a strong, 
useful, if somewhat awkward, support, but in childhood the removal 
of portions of the epiphyses and of the epiphyseal cartilages entails a 
progressive inequality in the limbs, due to loss of growth, and unless 
the limb is protected by mechanical means, deformity is the rule, even 
though the disease has been thoroughly removed. (Fig. 228.) Thus 
the treatment of routine is, in childhood, at least, protection ; protec- 
tion from the traumatism of motion, from the shock of impact with 
the ground and from the pressure of muscular spasm and contraction. 

Mechanical treatment, which is so difficult at the hip, is compara- 
tively easy at the knee and as has been stated the results are correspond- 
ingly better. At the hip joint one of the most common causes of 

Fig. 222. 




Extension and counter-extension in disease of the knee joint. (Marsh.) 



shortening and deformity is upward displacement of the femur upon 
the pelvis, but at the knee, if the limb is supported in the attitude of 
extension, the apposition of the broad surfaces of the femur and the 
tibia, prevents displacement, while muscular spasm, a symptom whose 
intensity is in proportion to the degree of harmful motion that is per- 
mitted, is easily controlled by efficient splinting. 

Reduction of Deformity. — The first step in treatment is the reduction 
of deformity that may be present, in order that the limb, at the begin- 
ning as well as throughout the entire course of treatment, may be in 
absolutely normal position ; and as the chief function of the leg is to 
support weight, the proper attitude is complete extension. Whatever 
motion the patient retains will then be at the point of greatest useful- 
ness. In the cases in which an opportunity for reasonably early treat- 
ment is offered, the only deformity is flexion, a deformity caused al- 
most entirely by muscular spasm ; although if it has persisted for some 
time secondary retraction of the muscles may be present. In this class 
of cases the spasm, and consequently the deformity, may be readily 
overcome by splinting the part while the patient is confined to the bed. 



TREATMENT. 



313 



The Plaster Bandage. — The most efficient splint is a close-fitting 
plaster bandage, applied from the groin to the ankle, or better, to in- 
clude the foot, in order to prevent oedema of the unsupported part, 
Avhich is common after the first dressing and until the circulation of 
the limb has become adapted to the new conditions. In the applica- 
tion of the bandage the bony prominences of the knee and ankle are 
protected by pads of cotton. A canton flannel bandage is then applied 
smoothly, and directly upon this, the light plaster bandage. At the 
second application, at the end of a week, the subsidence of the spasm 
will permit the straightening of 

the limb. In cases of longer F IG . 223. 

standing, several successive ap- 
plications of the bandage may 
be required, together with man- 
ual extension during the appli- 
cation ; or an anaesthetic may 
be administered which, reliev- 
ing the muscular spasm, will 
allow of immediate replace- 
ment. Under anaesthesia the 
more resistant deformities may 
be reduced by traction and by 
slight leverage, the head of the 
tibia being supported and 
drawn forward by the hands, 
as the deformity is gently re- 
duced. 

Traction. — Deformity may 
be reduced also by traction with 
the weight and pulley, the leg 
being supported so that no di- 
rect leverage is exerted at the 
seat of disease. (Fig. 222.) 

The Billroth Spint. — In 
more resistant cases the Billroth 
splint as modified by Stillman, 
may be employed. A thick 
pad of felt is placed over the 
upper surface of the condyles of 

the femur and a thinner pad in the popliteal region over the upper border 
of the tibia. Other points that may be subjected to pressure are simi- 
larly protected, especially the dorsum of the foot and the perineum. A 
plaster bandage is then applied from the groin to the toes, made espe- 
cially thick and strong in the popliteal region. On either side of the 
knee, two curved slotted steel bars attached to expanded tin splints and 
joined to one another by an adjustable bolt, are incorporated in it. (Fig. 
223.) When the bandage hardens, it is completely divided into two parts, 
by a circular cut about the knee and the bolts in the slots are so adjusted 




Tuberculous disease of the knee in an adult, 
with the form of Billroth splint used at the Hos- 
pital for Ruptured and Crippled. 



314 



TUBERCULOUS DISEASE OF THE KNEE JOINT 



or 



Via. 224. 




as to form a hinged splint, the center of motion being somewhat above 
and in front of the knee joint. When the limb is slightly extended, the 
position of the hinges has a tendency to lift the tibia and to separate it 
from the femur. This straightening opens the cut in the popliteal re- 
gion, which is held open by a wedge of cork. In this manner, by the 
insertion of larger wedges, the limb is gradually straightened from day 
to day until the deformity is overcome, or until a new bandage is re- 
quired. If the pressure on the front of the femur, when the leverage 
is exerted, becomes painful, a part of the padding is removed. 

Forcible Correction. — In very resistant cases, division of the 
contracted parts by subcutaneous or open incision, may be required ; 
the Goldthwait genuclast may be used. (Fig. 224.) The more 

violent methods should not be employed 
during the active stages of the disease; 
and whenever considerable force is re- 
quired, in young subjects, the possibility 
of separating the epiphysis of the femur, 
forcing it backward and thus pressing 
upon the popliteal vessels, should be 
borne in mind. 

Mechanical Treatment. — The most 
efficient mechanical appliance for the 
treatment of tuberculous disease at the 
knee, is the Thomas Knee Brace. This 
consists of two lateral uprights which 
support the limb on either side, termi- 
nating below the foot in a crossbar shod 
with leather or rubber, which serves as 
a stilt, and above in a ring that fits the 
upper extremity of the thigh, and sup- 
ports the weight of the body. The brace 
is made of iron wire from three-six- 
teenths to three-eighths of an inch in 
thickness. The ring is of an irregular 
ovoid shape, flattened in front, expan- 
ded behind, and wider on the inner than 
on the outer side. (Fig. 225.) This 
ring is welded to the uprights at a lateral and antero-posterior inclina- 
tion. The lateral inclination forms an angle with the inner bar of 135 
degrees (Fig. 227), the antero-posterior inclination forms an anterior 
angle of 145 degrees (Fig. 225) with the same upright, which is set 
upon the ring at a point slightly in advance of its fellow. The objects 
of the shape of the ring and of its inclination are these : its anterior 
part is flat because the surface of the groin is flat; its posterior segment 
is expanded to accommodate the thickness of the buttock, the antero- 
posterior inclination allows the ring to rest comfortably beneath the 
tuberosity of the ischium. The lateral inclination is made neces- 
sary by the greater length of the outer bar which, in order to assure 



Goldthwait' s genuclast for the correc- 
tion of flexion deformity and subluxation 
at the knee. 



MECHANIC A L TEE A TMENT. 
Fig. 225. Fig. 226. 



315 




The Thomas knee-splint, showing the 
unner bar, B, placed farther to the front than 
the outer bar C ; A is the lowest part of the 
Ting ; upon this rests the tuberosity of the 
ischium. 

Fig. 227. 



The ring of the Thomas knee- 
splint after padding. (Ridlon.) 



Fig. 228. 





Showing the front of the ring of the 
Thomas knee splint. 



Showing the back of the ring of the 
Thomas knee splint. (Ridlon. ) 



318 



TUBERCULOUS DISEASE OF THE KNEE JOINT. 



Fig. 229. 



better support and less pressure, rises above the level of the trochanter 
major. 

The ring is made somewhat larger than the thigh to allow for pad- 
ding with felting, w hich should be thicker on the inner and posterior 
surface, where the weight is borne, than on the anterior and outer part. 
The padding is then smoothly covered with basil leather. As used at 
the Hospital for Euptured and Crippled, the brace is made from two 

to three inches longer than the leg, to 
serve as a stilt like the hip splint. To 
the foot piece two straps are attached on 
either side to provide for traction on the 
limb and for the support of the brace. A 
band of leather is drawn between the 
bars at the upper third and another at 
the lower third of the brace, to serve as 
supports for the thigh and calf. Adhe- 
sive plasters, reaching from the knee to 
the ankle, provided with buckles above 
the malleoli, having been applied, the 
ring is pushed firmly against the per- 
ineum and is held in position by buck- 
ling the straps to the adhesive plasters 
with as much traction as the comfort of 
the patient will permit. The thigh and 
leg supports should fit the parts per- 
fectly; the knee is then fixed in its place 
by a bandage drawn tightly about it and 
the lateral bars, and a strap is applied 
about the ankle. (Fig. 229.) In cases in 
which the joint is sensitive and in which 
there is a tendency to deformity, the en- 
tire limb is in addition enclosed in a light 
plaster bandage, so-called " skin fitting/ 7 
applied directly upon a flannel bandage. 
If the brace is attached by means of 
the adhesive plaster straps, a certain 
amount of traction is assured, together 
with additional accuracy of adjustment ; 
and by the traction and by the direct 
pressure on the knee the slighter degrees 
of deformity may be reduced without discomfort. In acute cases pre- 
liminary rest in bed is advisable, and crutches may be employed in the 
early stages of ambulatory treatment. But during the greater part of 
the disease the splint serves as a perineal crutch and by the use of slight 
corrective force when the plaster bandages are applied, or by traction 
at times toward one or the other upright, lateral distortion of the limb 
may be corrected during the course of treatment. This brace may be 
used in the treatment of very young children, if it is carefully fitted 




The Thomas knee brace. 



EXTRA-ARTICULAR DISEASE. 



317 



Fig. 230. 



I 



and if the parts are kept clean and dry, and it is an effective brace for 
all ages and for all conditions of disease. 

The Caliper Brace. — The traction may be discarded and the brace may 
be held in position by a shoulder band, or it may 
be used as a so-called caliper splint. In this form 
it was almost exclusively employed by Mr. Thomas 
in his later practice and at the present time by 
Ridlon, 1 the long brace being used simply for a 
bed splint. As a caliper brace the two bars are 
<3ut off and turned directly inward at a right 
angle, are inserted into a steel tube which is passed 
through the heel of the shoe. The bars are made 
slightly longer than the leg so that the patient's 
heel is lifted nearly an inch from the inside of 
the shoe when walking ; thus the jar of impact 
with the ground is prevented. The brace is fixed 
in position by a leather band beneath the knee and 
another beneath the calf, and the limb is held exten- 
ded by pressure pads applied to the thigh and leg, 
as illustrated. (Fig. 230.) Ridlon uses the brace 
to reduce deformity by direct pressure backward 
on the knee by means of bandages, opiates being 
given to relieve pain. 

Other braces may be employed, for example the 
traction hip splint (Figs. 203, 204), but as the 
Thomas brace answers every requirement, it seems 
unnecessary to describe others in this connection. 

Treatment During Convalescence. — During the 
active stage of the disease the brace must be 
worn day and night ; during the stage of recovery 
it may be removed at night, to allow for motion 
at the knee, and later a form of walking brace 
(Fig. 205) that will allow a limited motion at the 
knee, may be of service ; but this is not an essen- 
tial in treatment. If a certain amount of knock 
knee remains after recovery, it may be overcome 
by the use of a Thomas knock knee brace which 
will also serve as a protective splint. 

The indications of cure have been discussed 
under hip disease. In brief, when sufficient time 
has elapsed to permit of natural cure, when there 
has been no symptom of active disease for months, 
when muscular spasm has disappeared, one may 
tentatively remove the brace in the manner de- 
scribed. But any symptom of disease and par- 
ticularly increasing limitation of the range of motion, or a tendency 
toward deformity, indicates the necessity for continued protection. 
1 Trans. Am. Orth. Ass'n, Vol. VI. 



The caliper splint. E, 
the ring around the upper 
part of the thigh ; A, pad 
for backward pressure ; B, 
bandage ; C, bandage ; F, 
leather sling for support at 
the back of the limb ; D, a 
strip of bandage fastening 
together the pressure pads 
to prevent slipping and con- 
sequent loss of pressure. 
(Ridlon and Jones.) 



318 TUBERCULOUS DISEASE OF THE KNEE JOINT. 

If anchylosis be present, supervision and occasional treatment will 
be required during the period of growth in order to prevent deformity. 

Extra- Articular Disease. — In certain cases, especially in young chil- 
dren, the disease about the epiphyseal cartilage of the femur or of the 
tibia, may find its way to the exterior of the bone before it perforates 
the capsule. This is suggested by local sensitiveness and swelling over 
one of the condyles of the femur or about the head of the tibia. In 
such instances, the thorough removal of the disease is indicated, or if a 
Roentgen picture shows that the disease is accessible, even though it is 
not immediately below the surface, an exploratory operation may be 
advisable. In favorable cases prompt operative intervention may cut 
short the course of the disease. 

Abscess. — Abscess is present as a complication in about one-third of 
the cases that have received efficient protection, and in a larger per- 
centage of the cases in which treatment has been neglected. 

It was present in 51 per cent, of Koenig's cases 1 and in 47 per cent, 
of three hundred final results reported by Gibney. 2 At the knee as 
at other joints, the infected abscess is the most dangerous complication 
of the disease, as is illustrated by Koenig's statistics. 

Death rate in cases without abscess 25 per cent. 

" " " " with " 46 per cent. 

Although in many instances, abscess indicates an extensive and de- 
structive disease of the bone, yet the exhausting suppuration that is 
an indirect cause of death, is suppuration from infected areas in the 
thigh and leg, which may have little direct relation to the extent of 
the original disease. It should be the aim in treatment to prevent this 
burrowing of fluid after the capsule has been perforated, and to prevent 
over-distention of the capsule even, in order to lessen the macerating 
effect of the tuberculous fluid upon the cartilages. When the fluid within 
the capsule is of an appreciable amount, and when it is increasing in 
quantity, it may be removed by aspiration ; or, a better procedure is to 
incise the capsule. This will allow a thorough removal of its fluid 
and solid contents, after which the opening may be closed with sutures. 

Tuberculous abscess which has perforated the capsule may be treated 
in the same manner, or it may be drained subsequently, according to 
the indications. Unless the abscess is infected, careful bandaging of 
the thigh and leg should prevent burrowing. 

Synovial Tuberculosis. — In the forms of synovial tuberculosis that 
resemble chronic synovitis the fluid may be evacuated by an incision in 
the capsule which will allow for exploration and for removal of the 
fibrinous masses that are often present. Afterwards the interior of 
the joint may be treated with an application of a strong solution of 
chloride of zinc, or carbolic acid. This sets up an active inflammation 
which causes adhesions within the capsule, and exerts a favorable in- 
fluence on the course of the disease. The injection of iodoform emul- 

1 Trans. Am. Orth. Ass'n, Vol. VI. 2 Am. Jour. Med. Sci., Oct., 1893. 



OPERATIVE TREATMENT. 319 

sion has been extensively employed in the treatment of tuberculosis of 
the knee at the Hospital for Ruptured and Crippled, but no decided 
benefit has been observed. Theoretically its use should modify the in- 
fectious quality of the tuberculous fluid, and lessen the danger of in- 
fection with pyogenic germs, and on this ground, rather than because 
it actually shortens the course of the disease, it may be recommended. 
(See Bier's treatment, page 203.) 

Arthrectomy. — When, as in exceptional cases, the disease is progres- 
sive and shows no tendency toward recovery, and particularly if an 
infected abscess communicating Avith the joint makes efficient drainage 
difficult, the operation of arthrectomy may be indicated. 

An Esmarch bandage having been applied, the joint is thoroughly 
exposed by a curved anterior incision passing above or below or 
through the patella, and all the diseased tissue is removed ; that in the 
soft parts is cut away, and foci in the bone are removed with the chisel 
and scoop. If infection be present the joint may be packed with gauze, 
the leg being fixed in the position of flexion ; but in other instances 
the wound is closed, with or without drainage as may seem advisable. 
In a large proportion of cases primary healing may be obtained. By 
the procedure one may hope to cure the disease, but in all but excep- 
tional cases the functional result will be anchylosis. The operation 
has the advantage over excision in that less bone is removed, and that 
the epiphyseal cartilages, in part at least, remain ; thus the immediate 
as well as the ultimate shortening is less than after excision. 

Results of Arthrectomy. — The direct death rate of the opera- 
tion is small. In 150 cases, reported by Koenig, but 3 deaths were 
attributable to the operation itself. The final results in 1 1 4 of these cases, 
in which the operation was performed in childhood, were as follows : 

Patients cured and living 90 

Cured of the local disease but not living 

at the time of the investigation 10 

Practically cured, insignificant fistulas 

remaining 2 

T02— 8 9. 5 per cent. 

Living, not cured 5 

Deaths before the cure of the local dis- 
ease 7 

T2— 10. 5 per cent. 

Thus in 89 per cent, of the cases the operation was successful as far 
as the cure of the local disease was concerned. In 75 per cent, of the 
successful cases, immediate cure was attained ; in 25 per cent, fistulas 
persisted for a longer or shorter time. In 10 cases some motion was 
retained, but in the others anchylosis followed the operation. In about 
70 per cent, of the cases the limb was practically straight ; in 30 per 
cent, it was distorted. This shows the necessity of continued super- 
vision during the growing period of all cases in which anchylosis is 
present from whatever cause. 



520 



TUBERCULOUS DISEASE OF THE KNEE JOINT. 



In 48 cases in which the operation had been performed before the 
tenth year, and in which the limbs were straight, the influence of the 
operation on the growth was investigated. 





Years elapsed 


Number of 


Average Shortening 




since operation. 


cases. 


in Cm. 




2 


6 


1 




3 


5 


1.6 




4 


4 


1 




5 


3 


2 




6-7 


19 


2 




8-13 


11 


2.5 



Fig. 231. 



These measurements indicate that the shortening is not likely to be 
very great as a result of the operation, certainly very much less than 
after complete or even partial excision, performed at the same age. 

Excision. — Excision of the joint 
in childhood has been practically 
abandoned because of the great 
shortening that follows complete 
removal of the epiphyses, and be- 
cause so-called partial excision, that 
is the removal of thin sections of 
bone from the surfaces of. the 
femur and tibia leaving the carti- 
lages, is usually an unnecessary 
operation, in the sense that disease 
that might be cured by this proce- 
dure might have been cured by 
conservative methods. 

Early excision in adult cases is 
often indicated because it will assure 
a cure of the disease in a short 
time, whereas mechanical treat- 
ment will require years of dis- 
ability with no certain prospect of 
absolute cure at the end of the 
period. If, therefore, the disease 
has progressed sufficiently to in- 
dicate that the natural cure would 
result in anchylosis, or if the time 
of disability is of importance to the 
patient, early excision may be ad- 
vised in the case of the adult, or 
adolescent, whose growth is nearly completed. 

The operation is performed under the Esmarch bandage, and the 
joint is exposed by the anterior incision, as in the operation of arthrec- 
tomy. All the diseased tissues are cut away and sections of the bones, 
parallel to the articular surfaces, are removed, sufficient in depth to 




Deformity and shortening resulting from 
excision of the knee in childhood. 



PRO GNOSIS. 321 

include all the diseased area. If the sections are so made as to 
allow the bones to be brought into close apposition, sutures through 
the periosteum will hold them in position, without nails or wiring. 
The vessels having been ligated, the wound may be closed with 
or without drainage, as may be indicated, a plaster of Paris dressing 
is applied, and the limb is elevated. Mechanical support is of 
service in the after-treatment in lessening the discomfort and hasten- 
ing the cure. 

Results of Excision. — In Koenig's statistics of three hundred 
excisions, 6 deaths were due directly to the operation, and 23 others 
occurred during the course of after-treatment; a total of 29 (9.6 per 
cent.). 

In 23 instances amputation was afterwards performed because of 
failure of the operation. The good results are classed by Koenig as 
75 per cent., the bad as 25 per cent. In 193 cases, the position of 
the limb in after years was investigated. It was straight in 175, dis- 
torted in 18 ; all but one of this latter group being in children. 

Amputation. — This operation is indicated as a life-saving measure. 
When the disease is so extensive as to require complete removal of 
the epiphyses, in early childhood, amputation is the preferable opera- 
tion, as the limb, aside from requiring constant protection to prevent 
deformity, will be so short as to be of little practical use. 

Operations for the Relief of Final Deformity. — If the joint is anchy- 
losed in an attitude of marked flexion, the limb may be straightened 
by the removal of a sufficient wedge of bone from the joint. Slighter 
degrees of flexion may be remedied by linear osteotomy of the femur. 

Genu valgum may be corrected by a similar operation. 

Prognosis. — The most important statistical evidence on the course 
and the outcome of tuberculous disease of the knee joint in childhood, 
has been presented by Gibney. The statistics completed in 1892 were 
the result of an investigation of four hundred and ninety-nine cases 
treated during a period of twenty years, 1868-1887. In .but three 
hundred of these could definite information be obtained. 1 

Eighty-seven per cent, of the cases were in children, and 51 per 
cent, of the patients were less than five years of age at the inception of 
the disease. 

The cases were divided into three classes, according to the treatment 
that had been followed : 

1. The expectant treatment. In this class no apparatus was em- 
ployed or, if employed, it was inefficiently used. 

2. The fixation treatment. In this class the joint was more or less 
efficiently splinted, but not protected from impact with the ground. 

3. The protective treatment. In this class the joint was both 
splinted and protected from jar, and the mechanical treatment was effi- 
cient. 

1 Am. Jour. Med. Sci., October, 1893. 
21 



322 TUBERCULOUS DISEASE OF THE KNEE JOINT. 

The results were classified as follows : 









a 




q 






















a 


"3 




a 












CO 














-S 




T3 




« 




ft 

2 


c3 
0> 


11 






H 


W 


^ 


" 


13 


O 


Expectant 


71 


5 


3 


3 


9 


51 


Fixation 


190 
39 


9 



1 



35 
2 


31 
11 


114 


Protection 


26 




300 


14 


4 


40 


51 


191 



Mortality. — The total deaths in the 300 cases were 40 (13.3 per 
cent.); 26 of these were from causes directly or indirectly connected 
with the disease (8.6 per cent.), viz. : 

Operative shock 1 

Prolonged suppuration. 16 

Tuberculous meningitis 6 

Phthisis 3 



Intercurrent diseases. 



26 
.14 
40 



Function. — The functional results, as regards motion, in the cases 
in which conservative treatment was continued to the end, including 
the cases still under observation, 242 of 300, were as follows : 





Total. 


Motion retained. 


Anchy- 
losed. 


Expectant 


60 
145 

37 


44 or 7 per cent. 
113 "77 " 
34 "95 " 


16 

32 


Protection 


3 




242 


191 "79 " 


51 



Of the 191 patients who retained a movable joint 74 had had ab- 
scess, 3 or more cicatrices being present in 39. 

As to the range of motion in 74 it was from 45 degrees to normal 
and in 41 more than 90 degrees, thus 30 per cent, of the patients re- 
tained a fair range of motion. 

Deformity. — In 51 cases anchylosis was present, in 16 of these the 
limb was practically straight, in 35 it was flexed more than 30 degrees 
(69 per cent.). 

These statistics again illustrate the great tendency toward deformity, 
when during the growing period there is anchylosis at the knee from 
whatever cause. 

In the 191 cases in which motion was retained the limb was prac- 
tically straight in 125 (65 per cent.). In 49 others the flexion was 
less than 25 degrees and in but 16 could the deformity be classed^ as 
bad (8 per cent.). 

In 10 cases only did relapse occur after apparent cure. 

In but 16 of the 449 cases was there involvement of other joints 



GENERAL CONCLUSIONS. 323 

while the patients were under observation (3.2 per cent.). In 8 of 
these the spine was involved, in 2, the hip, and in 6 other joints. 

The influence of age upon the death rate, and the ultimate causes of 
death, are illustrated by Koenig's statistics, the death rate being much 
higher, at least in the cases in early childhood, than in this country. 

According to Koenig's statistics, the death rate, direct and indirect, 
from disease of the knee joint, was as follows : 

323 children (1 to 15 years of age), deaths 65 (20 per cent.) 

225 patients (16 to 30 years of age), " 61 (24 per cent.) 

68 " (31 to 40 years of age), " 30 (44 per cent.) 

74 " more than 40 years of age " 45 (60 per cent.) 

Causes of Death. 

Deaths from causes not connected with the disease, 14 (2 per cent.). 
Deaths following operations, 18 (2.5 per cent.). 

Deaths caused by tuberculosis, 141 (22.5 per cent, of all cases and 80 per 
cent, of all the deaths). 

Tuberculosis of the knee 1 

Tuberculosis of the lungs 94 

General tuberculosis 30 

Tuberculous meningitis 7 

Acute miliary tuberculosis 3 

Tuberculosis of other parts 6 

141 

It may be noted that 16 of the 40 deaths in Gibney's cases were due 
to prolonged suppuration, and that of 51 cases still under observation 
26 had been treated for ten years or longer, and were still uncured. 
This indicates, that in a larger proportion of the cases conservative 
methods should have been supplemented by more radical treatment. 
Still, taken as a whole, the results, although the mechanical treatment 
was, in many instances, far from efficient, are much better than any 
others that have been presented. 

General Conclusions. — On this evidence the following conclusions 
seem to be justified. The death rate in childhood from all causes 
should be less than 10 per cent. The duration of treatment is from 2 
to 5 years. Recovery with a useful range of motion, when the diagnosis 
has been made at an early stage and when efficient mechanical treat- 
ment has been employed, may be predicted in 50 per cent, of the cases. 

Deformity can always be prevented by treatment and by super- 
vision. Under favorable conditions, radical operations are not often 
indicated, but when indicated, they should not be delayed too long. 
Amputation of the limb should prevent death from prolonged suppura- 
tion. In a certain proportion of cases the disease may be cut short by 
early exploratory operations, for the removal of foci of disease in the 
bone before the joint has become involved. 

Although the benefits of protective treatment are as evident in dis- 
ease of the adult as in childhood, yet early operation is often indicated 
in this class, because of the necessity for shortening the period of dis- 
ability, and because excision assures a straight and useful limb. 



CHAPTER X. 

NON-TUBEKCULOUS AFFECTIONS AND DEFORMITIES 
OF THE KNEE JOINT. 

Strains and Injuries of the Knee in Childhood. 

Injury of the knee in childhood may cause local discomfort and 
persistent flexion of the leg, even when but little synovial effusion is 
present. In this class of cases the application of a plaster bandage is 
of service in resting the part and preventing further injury. The 
importance of treating promptly slight injuries of the joints in child- 
hood, especially in the class of patients predisposed to tuberculous 
infection, has been mentioned already in the consideration of hip 
disease. 

Synovitis. 

Acute traumatic synovitis is properly treated, immediately after the 
injury, by splints, by elevation of the limb, by the application of ice 
bags and the like ; but after the acute symptoms have subsided the 
absorption of the effused fluid is aided by functional use of the limb, 
if the joint is properly protected. One of the most efficient methods 
of treatment is that by means of the adhesive plaster strapping, advo- 
cated by Cottrell and Gibney. The entire surface of the knee, except 
a narrow space in the popliteal region, is firmly strapped with over- 
lapping layers of adhesive plaster, extending from the upper third of 
the leg to the middle third of the thigh ; and over this a flannel band- 
age is applied ; or if the leg is swollen, the entire limb should be 
firmly bandaged with elastic stockinette bandage, from the toes to the 
upper third of the thigh in addition. (Fig. 238.) The adhesive plaster 
serves as a support which allows a certain degree of motion, sufficient 
to stimulate the circulation, and thus to hasten the restoration of the nor- 
mal condition. If greater compression is desired, the entire joint may 
be covered with the adhesive plaster as suggested by Hoffmann. 1 A 
pad of cotton is placed in the popliteal space, a close-fitting stocking 
leg is drawn over the knee and about this circular bands of plaster are 
drawn as tightly as the comfort of the patient will permit. The adhe- 
sive plaster strapping is renewed from time to time, as the swelling 
diminishes and its use is continued until the symptoms have entirely 
disappeared. 

Chronic synovitis may be treated in a similar manner, although if 

JN. Y. Med. Jour., January 27, 1900. 



PREPATELLAR BURSITIS. 325 

the effusion is persistent the fluid may be removed by aspiration. If 
the ligaments are lax, a supporting brace may be required for a time 
(Fig. 152), aud massage and exercises are of service in the stage of 
recovery. 

Infectious Arthritis. 

Suppurative arthritis in this, as in other joints, should be treated by 
free incisions, and efficient drainage should be assured. Under proper 
treatment practically perfect recovery is not unusual. Mechanical 
protection is usually required after the immediate svmptoms are relieved. 
(See page 208.) 

RHEUMATOID ARTHRITIS. 
Osteo-Arthritis. 

In this disease several joints are usually involved, but occasionally 
the affection may be confined to the knee. The early symptoms are 
stiffness, discomfort and pain more noticeable in damp weather, and 
often creaking sensations in the joint are appreciable to the patient. 
At intervals the symptoms may be more acute and the joint becomes 
hot and swollen, as in rheumatism ; as a rule, however, they are sub- 
acute in character. The progress of the affection is slow, the joint 
becomes somewhat enlarged and irregular in outline, the range of 
motion becomes more restricted, and flexion of the limb, after a time, 
persists. (See page 212.) 

Treatment. — The general and constitutional treatment of rheuma- 
toid arthritis does not require especial consideration here. Locally, 
massage and the hot-air bath, may add to the comfort of the patient 
and increase the mobility of the joint, in the early stage of the affec- 
tion, at least. Static electricity has been employed with advantage 
in certain cases. The application of the cautery and stimulating lini- 
ments are useful in relieving pain, and the support of a flannel band- 
age adds much to the comfort of the patient. 

Prepatellar Bursitis. ,], 

Synonym. — Housemaid's Knee. 

A chronic enlargement of the bursa lying over the patella and its 
ligament, is common among those who have to kneel much of the 
time, hence the popular name. Occasionally cases of acute bursitis, in 
which there is considerable effusion into the sac, are seen, and these 
are sometimes mistaken for synovitis of the knee. 

Treatment. — In acute cases, strapping the front of the knee with 
strips of adhesive plaster which will limit motion and provide compres- 
sion, is an effective treatment. If the effusion is considerable, it may 
be relieved by aspiration. In chronic cases, cure can be attained only 
by the removal of the thickened sac. 



326 NON-TUBERCULOUS AFFECTIONS OF THE KNEE JOINT. 

Pretibial Bursitis. 

Beneath the ligamentum patellae, occupying the space between the 
tendon and the periosteum of the tibia, is the deep pretibial bursa. It 
is, according to the investigations of Lovett, 1 as wide or somewhat 
wider than the tendon ; its upper border is on a level with the joint, its 
lower border reaches to the tubercle of the tibia, and being slightly 
longer on the outer than on the inner border, it is somewhat triangular 
in shape. It does not communicate with the knee joint. 

Enlargement of this bursa is, as a rule, the result of injury, but, as 
bursitis elsewhere, it may be a complication of infectious disease, rheu- 
matism and the like. 

Symptoms. — The symptoms are stiffness at the knee and pain on 
sudden movement, especially when strain is exerted on the tendon by 
complete flexion or extension of the leg as in active use. The tubercle 
of the tibia seems enlarged and is sensitive to pressure, and a swelling 
on either side of the ligament is usually evident. 

Treatment. — The affection, if at all acute, may be treated by re- 
lieving the strain and pressure on the tendon, by fixation of the limb 
for a time in a plaster bandage, or other form of splint. Later, the 
adhesive plaster strapping will provide sufficient fixation and pressure. 
The absorption of the fluid may be hastened by the application of the 
cautery. If the swelling is persistent, the fluid may be removed by aspi- 
ration or incision of the sac. Its complete removal is not often necessary. 

Enlargement of the Superficial Pretibial Bursa. 

A small bursa, lying upon the insertion of the ligamentum patellae, 
may become enlarged, causing an apparent hypertrophy of the tubercle of 
the tibia. It may be treated by strapping with adhesive plaster, and the 
prominent tubercle should be protected by some form of bunion plaster. 

Bursae and Cysts in the Popliteal Region. 

Simple inflammation of the bursa lying between the inner head of 
the gastrocnemius and the semimembranosus muscle, may cause a 
fluctuating swelling on the inner side of the popliteal region. Cysts 
in the popliteal region usually communicate with the knee joint and 
are complications of rheumatic or tuberculous disease. They are of 
interest principally from the diagnostic standpoint. 

Internal Derangement of the Knee Joint. (Hey.) 

The term internal derangement signifies sudden interference with 
the function of the joint which may be due to : (a) Loose bodies in 
the joint ; (6) Displacement of a semilunar cartilage ; (c) Other injury. 2 

Loose Bodies in the Knee Joint. — Loose bodies in the knee 
joint may be composed of portions of fibrin, fragments of synovial mem- 

1 Boston City Hospital Reports, Eighth Series, 1897. 
2 W. H. Bennett, Lancet, Jan. 6, 1900. 



INTERNAL DERANGEMENT OF THE KNEE JOINT. 327 

brane or bits of cartilage or bone and the like. In certain forms of 
synovial tuberculosis and osteo-arthritis, these loose bodies may be 
present in large numbers, but from the therapeutic standpoint the 
important cases are those in which the joint is otherwise normal. In 
this class the foreign body is sometimes detected by the patient as a 
smooth, movable object on one or the other side of the patella ; but in 
many instances the first sign of its presence is interference with the 
function of the joint. After a sudden movement or when the knee 
has been flexed, as in the kneeling position, or without appreciable 
cause, severe pain in the knee is felt and the joint may be fixed in the 
position of flexion. By massage, manipulation, or spontaneously, the 
foreign body is dislodged from between the surfaces of the bones and 
movement becomes free and painless, but discomfort remains for a 
time and in most instances synovial effusion follows. These symptoms 
recur at intervals and the disappearance of the movable body from its 
accustomed place at such times demonstrates its relation to the dis- 
ability. 

Displacement of a Semilunar Cartilage. — Displacement of 
a semilunar cartilage is usually of traumatic origin, and it appears to 
be caused most often by an outward twist of the tibia upon the femur. 
The patient's limb is fixed in the attitude of flexion, and in certain 
instances an irregularity may be detected at the inner and upper border 
of the tibia. 

To replace the cartilage, the leg should be flexed then suddenly ex- 
tended and rotated inward. In some instances an anaesthetic may be 
required. The displacement is followed by discomfort and synovial 
effusion, and the accident having once occurred, is likely to recur ; the 
patient recognizing the character of the movements that are likely to 
cause the displacement, also the proper manipulation for its replacement. 

Injury. — In other instances, somewhat similar symptoms may fol- 
low injury at the knee, pinching of the synovial membrane, bruising 
of the cartilage or a strain of one of the ligaments within the joint, 
being assigned as causes. In cases of this character in which the symp- 
toms recur from time to time, the joint becomes weak and insecure, 
partly because of the repeated synovial effusions and partly because of 
the muscular relaxation. 

Treatment. — Immediately after the displacement or injury, the -oint 
should be splinted for a time, afterwards it may be protected by the ad- 
hesive plaster strapping, and when the effusion has been absorbed mas- 
sage and exercises for strengthening the muscles should be employed. 

In the more chronic cases in which the ligaments are lax, a brace 
which will permit antero-posterior motion, but prevent lateral mo- 
bility, may be required. The Campbell brace (Fig. 152) used by 
Shaffer, is a light and effective support that interferes little, if at all, 
with the use of the limb. If the diagnosis of displaced cartilage can 
be verified, and if it is the cause of persistent disability, it should be 
removed. And the same may be said of isolated foreign bodies, which 
are known to be the cause of the symptoms. 



328 NON-TUBERCULOUS AFFECTIONS OF THE KNEE JOINT. . 

Congenital Genu Recurvation. 

Synonym. — Anterior Displacement of the Tibia. 

The most common of the congenital deformities at the knee is the 
so-called genu recurvatum, in which the knee is bent somewhat back- 
ward, or in other words, the leg is hyper-extended on the thigh. The 
condition is often spoken of as an anterior dislocation, but there is no 
actual displacement, except in the extreme cases in which the tibia 
may be turned directly forward on the femur, even to a right angle 
or less. In the ordinary cases the range of extension is merely ex- 
aggerated, while flexion is limited or checked, principally by adaptive 
shortening of the quadriceps extensor muscle. (Fig. 232.) 

The appearance in well-marked genu recurvatum is very peculiar, it 
is as if the patient's leg were reversed, for the popliteal depression has 

Fig. 232. 




Congenital genu recurvatum. (Hoffa.) 



become a prominence and the range of over-extension seems to repre- 
sent normal flexion. In such cases the leg may be brought to the 
straight line, but greater flexion is resisted by the retracted tissues, and 
when the pressure of the hand is removed the leg is drawn back to the 
deformed position by the contraction of the quadriceps extensor muscle. 

Other Deformities and Malformations. — Genu recurvatum 
is not infrequently accompanied by varus or valgus deformity at the 
knee, more often by the latter, and by laxity of the ligaments. In 
many instances the patella is absent or is rudimentary and not infre- 
quently the deformity is accompanied by malformations or defective 
development of other parts. 

Seventy-eight cases were collected by Potel. 1 In thirty-seven in- 
stances the deformity was limited to one side, in the others both legs 

1 Etude sur les Malformations Congenitale du Genoa. Lille, 1897, Imp. L. Danel. 



CONGENITAL DISPLACEMENT OF THE PATELLA, 329 

were affected. In fifty cases the condition of the patella was noted, in 
twenty-six of these it was absent or rudimentary. Twenty of the cases 
were accompanied by talipes. 

Etiology. — The deformity in cases of simple recurvation may be 
explained by an abnormal and fixed position in utero, and in cases seen 
soon after birth the mechanism is clearly shown by the habitual atti- 
tude. The thighs are sharply flexed on the body, the dorsal surfaces 
of the hyper-extended knees are in relation to the abdomen, while the 
feet may be brought into contact with the face or trunk, according to 
the degree of deformity. The retarded development of the quadriceps 
extensor muscle explains the rudimentary patella which is often an ac- 
companiment of the deformity. 

Treatment. — The treatment of the hyper-extended knee is very sim- 
ple. It consists in massage of the atrophied and contracted muscle, 
combined with more or less forcible manipulation in the direction of 
flexion. If, as is often the case, the leg seems to be drawn forward by 
spasmodic muscular action, the methodical massage should be combined 
with the use of a simple posterior splint. 

In the more extreme cases manual force maybe applied under anaes- 
thesia, and the deformity may be overcome at one or several sittings, 
according to the resistance of the contracted parts. The leg is then 
fixed in a flexed position until the tendency to recurrence has been 
overcome. When the child begins to walk, a light lateral brace may 
be necessary to insure perfect functional use of the joint, as in many 
instances laxity of ligaments and muscular weakness may persist for a 
long time. 

Rudimentary or Absent Patella. 

As has been stated, a rudimentary patella is a frequent complication 
of genu recurvation, or of any congenital defect or deformity of the 
knee or limb that involves imperfect development of the quadriceps 
extensor muscle. In many cases of this type it is impossible to dis- 
tinguish the patella during the early months of infancy, but' later, a 
minute patella appears that slowly increases to an approximately nor- 
mal size. 

Absence of patella under the same conditions is less frequent, al- 
though Potel collected one hundred cases from literature. 

Treatment. — The treatment of rudimentary patella is included in 
the massage and stimulation of the atrophied or rudimentary muscle 
with which it is usually associated, and the support that the weak or 
deformed knee may require. 

Congenital Displacement of the Patella. 

The patella may be displaced upward as a result of extreme genu 
recurvatum, and in rare instances it may be displaced inward or down- 
ward, but far more often the displacement is outward. Fifty cases 
of this form are recorded, in most of which it was a complication of 
congenital genu valgum. 



330 NON-TUBERCULOUS AFFECTIONS OF THE KNEE JOINT. . 

Slipping Patella. 

This term is applied to an abnormal laxity of the supporting tissues 
that allows intermittent displacement of the patella upon, or to the 
outer side of, the external condyle. 

Etiology. — The disability is more common among females than 
males and is more often unilateral than bilateral. The abnormal mo- 
bility may be an inherited peculiarity ; it may be due to weakness of 
the quadriceps extensor muscle, or to imperfect development of the 
patella or of the external condyle ; or the original displacement may 
have been due to injury. In many instances, however, the predispos- 
ing cause is genu valgum, as a consequence of wmich the patella is car- 
ried toward the external condyle. 

Symptoms. — If the slipping of the patella is a frequent occurrence 
it causes comparatively little pain, but when the parts are less relaxed 
the displacement is likely to be followed by a certain amount of effu- 
sion into the joint and by the symptoms of a sprain. It is usually the 
result of a misstep or sudden movement when the thigh muscle is re- 
laxed or of extreme flexion of the leg. As a rule there is a sense of 
insecurity and weakness at the knee in those who are subject to the 
accident. 

Treatment. — The treatment varies according to the condition of the 
parts about the joint. If the displacement is the direct result of vio- 
lence the leg should be fixed for a time in a plaster bandage, which 
may be replaced by the adhesive plaster strapping or a knee cap. 
Later massage and muscle training should be employed. In cases in 
which the slipping has become habitual and particularly when the liga- 
ments of the joint are much relaxed, a light leg brace should be em- 
ployed to prevent lateral motion and to limit the range of flexion at 
the joint, if this predisposes to the displacement. 

Operative Treatment. — If the position of the patella that predisposes 
to the further displacement is a consequence of genu valgum the recti- 
fication of the deformity will, as a rule, remedy the secondary disabil- 
ity. If the displacement appears to be caused by laxity of the capsu- 
lar ligament, as well as by the abnormal position of the patella, an 
operation for the purpose of limiting the mobility and restoring the 
proper relation of parts may be conducted in the following manner : 
A long curved incision is made about the inner side of the knee, the 
lower extremity of which crosses the ligamentum patellae. The skin 
flap having been reflected the capsule may be divided on the outer side 
without disturbing the synovial membrane. The patella is then forced 
forward and the redundant tissue on the inner side is folded and sutured, 
or a section of the capsule may be removed, sufficient in size to hold 
the patella in its proper position. In extreme cases the tubercle of 
the tibia, with the attached tendon, may be removed and reimplanted 
on the inner aspect of the tibia, as performed by Wolff and Walsham. 

The limb should be held in the extended position for a time, and 
it should afterwards be supported by a brace or knee cap for several 



SNAPPING KNEE. 331 

months. Subsequently massage, and exercise of the weakened muscle 
will be of advantage. 

The operation for the dislocated patella has been performed in child- 
hood by Pollard, 1 and in early infancy by Bajardi. 2 

The method described is that of Bradford. 3 

Elongation of the Ligamentum Patellae. 

In certain cases the ligamentum patellae may be abnormally long so 
that the patella lies habitually above its proper position. This elonga- 
tion may be one of the evidences of general relaxation of the liga- 
ments of the knee, and thus a predisposing cause of the slipping pa- 
tella, or of abnormal mobility at the knee joint. 

Etiology. — The elongation of the tendon may be a congenital pecu- 
liarity or it may be acquired. It is often observed as an eifect of an- 
terior poliomyelitis, or of hemi- or paraplegia. 

Symptoms. — The symptoms of elongation of the ligamentum patel- 
lae, as distinct from those of the general laxity of the ligaments, that 
is often present, are weakness and disability, usually noticeable on walk- 
ing up or down stairs, or after over-exertion. Shaffer, who first called 
attention to the disability, thinks that it may be a predisposing cause 
of displacement of the semi-lunar cartilages. 4 

Treatment. — In this, as in other forms of insecurity or of abnormal 
mobility at the knee, a brace that allows only antero-posterior motion, 
will, as a rule, relieve the symptoms. If the ligament is of such a length 
as to require it, it may be shortened, or the tubercle of the tibia may 
be removed and implanted at a lower point, as suggested by Walsham.' 

Other Congenital Deformities at the Knee. 

Congenital displacements are uncommon. As a rule they are incom- 
plete and are caused by laxity of the ligaments and by defective for- 
mation of the bones or other parts. 6 

Snapping Knee. 

A very slight form of partial recurrent displacement, is the snapping 
or clicking knee not uncommon in early infancy, in which the tibia on 
sudden extension of the limb springs forward, or rotates outward, on 
the femur, with an audible snapping sound. This movement appears 
to be the result of voluntary muscular contraction combined with laxity 
of ligaments. In some instances the subluxation appears to cause pain 
or discomfort. The ability to displace the tibia on the femur by mus- 
cular action, is sometimes found in older subjects. 

1 Lancet, 1891, Vol. I., p. 988. 

2 Archiv di Ortoped., 1894, p. 209. 

3 Trans. Am. Orth. Ass'n, Vol. VIII. , p. 228. 

4 Ibid., Vol. XL 

5 Med. Week, February 17, 1893. 

6 Drehmann, Die Cong. Lux. des Kniegelenks. Zeits. fur Orth. Chir., Bd. 7, H. 4 r 
1900. 8 



332 NON-TUBERCULOUS AFFECTIONS OF THE KNEE JOINT 

Treatment. — The treatment of .congenital dislocations or subluxa- 
tions of the knee consists in reposition, support and massage of the 
weak part. The snapping knee may be supported by a flannel band- 
age, or in the more marked type of laxity of ligaments, it may be fixed 
for a time in a brace. Complete recovery is the rule. 

Congenital Contraction at the Knee. 

Slight limitation of the range of extension of one or both knees is 
not infrequent. As a rule it is easily overcome by massage and man- 
ipulation. In the more extreme cases there may be an actual de- 
formity of the femur, its lower extremity presenting a forward convex- 
ity, as in a case reported by Phocas. 1 

General Contractions. 

Congenital contraction at the knees of a more marked and resistant 
form may be combined with flexion contraction at the hip, or it may 
be one of a series of contractions at other joints. In the latter instance, 
other congenital deformities or evidences of defective development are 
usually present. For example, certain joints may be fixed in flexion 
or fixed in extension. In some instances the contraction or the partial 
anchylosis appears to be due simply to long-continued fixation in utero, 
and non-development of the muscles. In others, it appears to be a 
complication of so-called foetal rhachitis. 

Treatment. — The treatment consists in regular massage and manip- 
ulation, with the aim of increasing the range of motion. Deformity, if 
present, may be rectified in the usual manner. 

Prognosis. — The prognosis depends upon the cause of the contrac- 
tion or fixation. In most instances, under careful and continued treat- 
ment, the range of motion may be in great degree restored. 

Acquired Genu Recurvatum. 

Synonym. — Back Knee. 

Genu recurvatum, as the name implies, is a deformity in which the 
knee is habitually over-extended. The congenital form has been de- 
scribed. (See page 328.) 

Etiology. — Acquired genu recurvatum may be a simple local de- 
formity, or it may be secondary to weakness or distortion of other 
parts. Local or primary genu recurvatum may be an effect of rhachi- 
tis, or of disease or injury of the femur or tibia. In this form the 
femur may be curved sharply forward above the joint, or the upper 
extremity of the tibia may be bent backward at the epiphyseal junction, 
-and flexion may be limited by the obliquity of the articulating surfaces. 

More often the deformity is secondary. It may be, for example, an 

effect of equinus, either congenital or acquired, in which the knee is 

strained by the effort of the patient to place the heel upon the ground. 

It may be caused by the use of a traction brace in the treatment of hip 

1 Kevue d' Ortliopedie, January, 1899. 



ACQUIRED GENU RECURVATUM. 333 

disease, when the knee joint is not properly supported. It is one of the 
comparatively infrequent complications of disease at the knee joint, in 
which the leg has been supported by the brace in an extended or over- 
extended position. In rare instances it is the direct result of trauma- 
tism, when the leg has been suddenly forced into an over-extended 
position, and the posterior ligaments, and possibly the crucial ligaments 
also, have been ruptured or weakened. It is most often, however, an 
accompaniment of paralysis of the posterior thigh group, or of the 
gastrocnemius muscle, or both. 

In the majority of cases genu recurvatum is combined with a vary- 
ing degree of knock knee. In many instances there is an abnormal 
mobility at the joint that allows a certain amount of posterior displace- 
ment of the tibia, and in extreme cases, there may be well-marked 
subluxation. 

Symptoms. — The symptoms, aside from the deformity, are weak- 
ness and insecurity caused by the hyper-extension when weight is 
borne. If the deformity is extreme, the strain upon the weakened 
parts usually causes discomfort. Flexion is rendered difficult because 
of the abnormal relation of the joint surfaces and of the accommodative 
changes in the ligaments and muscles, so that in extreme cases the pa- 
tient swings the leg along in the extended or over-extended position. 

Treatment. — If the recurvatum is caused by deformity of the bones, 
the normal relations may be restored by osteotomy of the tibia or fe- 
mur, as may be indicated. Deformity secondary to distortions else- 
where, may be treated by remedying the primary cause. 

Traumatic genu recurvatum may be treated by fixation in the flexed 
position until the repair is complete, afterwards by massage and sup- 
port, if necessary. The ordinary form of over-extended knee, com- 
bined with lateral mobility, must be supported by a brace which per- 
mits only antero-posterior motion to the normal limit or slightly less. 
Whenever possible, massage and exercises should be employed. 



CHAPTER XI. 
DISEASES AND INJURIES OF THE ANKLE JOINT. 

Tuberculous Disease of the Ankle Joint. 

Disease of the ankle is the third in the order of importance, although 
it is far less common than is disease at the knee. 

In five consecutive years, 1,788 cases of tuberculous disease of the 
joints of the lower extremity were treated at the out-door department 
of the Hospital for Ruptured and Crippled. In 54.1 per cent, of 
these the hip joint was affected, in 36.2 per cent, the knee joint, and 
in but 9.7 per cent, the ankle joint. 

Pathology. — The pathology of tuberculous disease at the ankle dif- 
fers in no essential particular from that of disease of the hip and knee. 

Fia. 233. 




Tuberculous disease of the ankle and tarsus. A, disease of the ankle and sub-astragaloid joints ; B, 
cavity in the os calcis containing sequestrum. 

It does not therefore call for special consideration. It is of interest 
to note however, that abscess is a more common complication at this, 
than at the other joints. 

In 30 final results of disease at the ankle reported by Gibney, 1 ab- 
scess was present in 25, 83 per cent. In 78 final results reported by 
Prendlsburger 2 abscess was present in 68, 87 per cent., as contrasted 
with a percentage of 69 and 51 at the knee and hip respectively. This 
greater liability to abscess is very possibly apparent rather than actual, 
since the ankle joint is so superficial that fluctuation may be detected 
'Am. Jour. Obstetrics, April, 1880. 2 Loc. cit. 



ETIOLOGY. 



335 



here that would be overlooked at the hip. And because the tissues 
about the joint readily allow spontaneous opening at an early stage, 
before sufficient time has elapsed to permit of spontaneous absorption, 
that is so common in disease of the spine and hip. 

Situation of Disease. — Otto Hahn l has recently investigated the 
cases of tuberculous disease of the ankle and foot treated at Tubingen 
during the past fifteen years. These cases were 704 in number in 
685 patients, in 19 both feet having been involved. 

In 309 of the cases the disease was of the ankle joint. Of these 
51 per cent, were osteal in origin. The primary focus was in the 
internal malleolus in 11, the external in 7, in both in 5. It was in 
the astragalus in 116 cases. 

In 16 instances the disease of the ankle was secondary to primary 
infection of the os calcis, and in 5 cases both the astragalus and the os 
calcis were diseased. 

Etiology. — The etiology of tuberculous joint disease does not re- 
quire further comment. It may be noted, however, that tuberculous 
disease at the ankle is relatively more common in later childhood and 
adult life than is the same affection at the knee and hip. 

Of 1,000 cases of disease of the hip joint, 12 per cent, were in 
patients more than 10 years of age. 

Of 1,000 cases of disease of the knee joint, 25 per cent, were in 
patients more than 10 years of age. 

Of 339 cases of disease of the ankle joint, 30 per cent, were in pa- 
tients more than 10 years of age. 2 



Age at Incipiency of Ankle- Joint Disease in 339 Consecutive Cases 
Treated at the Hospital for Ruptured and Crippled. 



1 year or less 5 

2 years old 



3 


t< 


4 


(< 


5 


a 


6 


a 


7 


a 


8 


u 


9 


it 


10 


it 


11 


it 


12 


l i 


13 


li 


14 


a 


15 


11 


16 


li 


17 


11 


18 


11 


19 


a 


20 


a 


21 


a 


22 


ii 



5 


23 


42 


24 


43 


25 


44 


26 


34 


27 


24 


28 


19 


29 


8 


30 


9 


31 


9 


32 


11 


33 


8 


34 


4 


35 


4 


36 


4 


37 


6 


40 


2 


43 


4 


44 


3 


45 


3 


46 


4 


48 


5 


50 



years old 2 

" 2 

" 3 

" 3 

" : 4 

" 4 

" 2 

" 2 

" 

" 1 

" 2 

" 1 

" 

" 2 

" 2 

" 4 

" 1 

" 1 

" 4 

" 2 

" 1 

" „_1 

339 



1 Beitriige zur Klin. Chir., Bd. 26, H. 2, 1900. 

2 Statistics from Hospital for Ruptured and Crippled. 



336 DISEASES AND INJURIES OF THE ANKLE JOINT. 

Of the 339 patients 177 were males (52.2 per cent.) ; 162 were fe- 
males (47.8 per cent.). The disease was of the right ankle in 173 
cases ; of the left in 166. 

Age of the Patients Treated for Ankle-Joint and Tarsal Disease 
at Tubingen. (Hahn.) 

Males. Females. Total. 

ltolOyears 45 28 73 

11 " 20 " 149 91 240 

21 " 30 " 89 34 123 

31 " 40 " 32 28 60 

41 " 50 " 37 27 64 

51 " 60 " 35 26 61 

61 " 70 " 18 11 29 

71 " 80 " 6 17 

81 " _1 _0 _1 

412 246 658 

Of 658 patients 412 were males (62 per cent.) ; 246 were females 
(38 per cent.). In 27 the sex was not stated. 

Symptoms. — The symptoms are usually subacute in character, and 
are often mistaken for sprain or rheumatism. In some instances they 

Fig. 234. 




Tuberculous disease of the ankle. 



appear to follow an injury, but in the majority of cases in childhood no 
cause can be assigned. The ankle becomes sensitive to sudden move- 
ments, the patient limps, discomfort after over-use and pain at night 



DIAGNOSIS. 



337 



become noticeable. The limp differs in character from that caused by 
hip or knee disease. The patient walks with the foot rotated outward, 
bearing the weight upon the heel and upon the inner border, all active 
leverage being avoided. 

Deformity. — The primary deformity of ankle-joint disease, in the 
subacute cases, is valgus, induced apparently by the continued use of 
the limb in the passive attitude. In more advanced cases it becomes 
equino-valgus and when the limb is no longer capable of supporting 
weight, but is held pendant, the equinus deformity predominates, due 
partly to the force of gravity and partly to the muscular spasm. 

As has been stated, in the early stage the symptoms are those of a 

Fig. 235. 




Tuberculous disease of the sub-astragaloid joint. 



persistent, somewhat painful disability at the ankle, causing stiffness, 
limp and at times pain ; later swelling and deformity appear. 

Physical Examination. — The joint is usually somewhat enlarged. 
In some instances the swelling is uniform, in others it is localized in 
front or behind one of the malleoli. This swelling is not, as a rule, 
like that of simple effusion into the joint, but the tissues have the pe- 
culiar elastic characteristic of thickening and infiltration. There is 
usually a perceptible increase in the local temperature, and pressure di- 
rectly upon the malleoli causes discomfort. The voluntary movements 
of the joint are restricted and passive movements show the characteris- 
tic reflex muscular spasm, limiting both dorsal and plantar flexion. 
22 



Fig. 236. 




The epiphyses of the lower extremities at the age of s*x years, showing the effect of operative re- 
moval of bone at the ankle joint for tuberculous disease at the age of 3 years, in causing subsequent de- 
formity of the foot and shortening of the limb. l*>») 



TREATMENT. 339 

Sub-astragaloid Disease. — If the astragalus is primarily dis- 
eased, the symptoms are usually first apparent in the ankle joint, but 
in certain cases the joint between the astragalus and the os calcis is 
first involved, although this is more often the effect of primary disease 
of the os calcis. Disease at the sub-astragaloid joint is usually classed 
as ankle-joint disease, although the swelling is most marked at a point 
somewhat below the malleoli. (Fig. 235.) Forced lateral motion of 
the os calcis causes discomfort, and the range of adduction and abduc- 
tion of the foot is restricted, while dorsal and plantar flexion may re- 
main completely free. 

Diagnosis. — The principles of differential diagnosis of tuberculous 
disease from other affections have been considered in detail in the de- 
scription of disease of the spine and of the larger joints. 

In childhood, a chronic, painful disease confined to a single joint in 
which motion is limited by muscular spasm, and in which there is a 
tendency to deformity, is almost certainly tuberculous in character. 

In adult life also the same principle applies, and distinguishes tu- 
berculous disease from rheumatism, rheumatoid arthritis or other gen- 
eral affections. Forms of infectious arthritis may be differentiated by 
the history. Sprains or other injury may be distinguished by the his- 
tory of the onset and by the absence of local signs of serious disease. 
In rigid flat foot the symptoms are localized at the medio-tarsal joint. 
It should be borne in mind, also, that the pain from a weak or injured 
foot is experienced as a rule only when it is in use, whereas in tuber- 
culous disease of the bone, pain is common when the part is not in use, 
and it may be particularly troublesome at night. 

Treatment. — In disease of this as of other joints functional rest is 
indicated. This necessitates fixation and stilting of the limb, efficient 
traction being manifestly impossible. The foot should be fixed in a 
light plaster bandage, extending from the extremities of the toes to the 
calf, at a right angle with the leg and in an attitude of slight supina- 
tion, in order to guard against the tendency toward valgus. This de- 
formity is very common after the cure of the disease and it often sub- 
jects the patient to the additional discomfort of progressive flat foot. 

Rfduction of Deformity. — If the foot has become distorted be- 
fore the patient is brought for treatment, the plaster bandage may be 
applied in the attitude of deformity, and at the subsequent applications 
of the dressing, when the muscular spasm is lessened, gentle manipu- 
lation will gradually overcome the malposition. Although in resistant 
cases immediate reduction of the deformity under anaesthesia may be 
required. Throughout the entire course of treatment the greatest at- 
tention must be paid to the attitude. Deformity is easily prevented, 
but it is often very difficult to correct, especially during the later stages 
of the disease, when the tissues are infiltrated and sensitive, and when 
discharging sinuses are present. 

Other retentive appliances may be employed, but they are inferior 
to a properly applied bandage which holds its place by accuracy of ad- 
justment, which most effectively prevents motion, and which exercises 



340 DISEASES AND INJURIES OF THE ANKLE JOINT. 

a certain degree of compression upon, and general support of, the swol- 
len joint. The bandage is renewed at intervals of a month, or longer 
if it is properly protected by a light shoe or slipper. 

The most satisfactory brace to serve as a stilt in connection with the 
local support is the Thomas brace, which has been described in the 
section on disease of the knee joint. (Fig. 229.) 

When patients are treated efficiently the discomfort or inconvenience 
attending the disease is slight. As a rule, the swelling of the joint 
becomes more localized and finally an abscess appears beneath the skin. 
It is then advisable to remove the fluid and other contents, by means 
of a simple incision. In most instances a sinus persists for a time. 
If the discharge is slight, the part may be dressed with ichthyol, 
balsam of Peru or other application, and the whole inclosed again in 
the plaster bandage ; or, if it be more profuse, an opening may be 
made and the dressing applied outside the plaster bandage. 

Operative Treatment. — Early operation, especially gouging opera- 
tions, should be avoided. An effective operation of this character often 
involves the sacrifice of bone that would be spared in the natural cure, 
thus it entails an irregularity in the growth, and causes deformity in 
after life, which may be irremediable. (Fig. 236.) 

Similar operations in the treatment of fistulse, or abscess, while the 
tissues are thickened and cedematous, and while the disease within the 
joint is active, should be postponed until the process of repair is more 
advanced. During the stage of convalescence, however, cure may be 
hastened by the removal of persistent foci of disease, or sequestra in 
the bone, or tuberculous tracts in the overlying soft parts. 

In the adult or adolescent, and in exceptional cases in childhood, 
operative removal of the disease may be indicated, and if it is confined 
to the ankle joint, the removal of the astragalus, which is usually the 
primary seat of infection, is the operation of choice. 

The operation is performed under the Esmarch bandage ; a curved 
lateral incision is made passing beneath the external malleolus from 
the neighborhood of the tendo-Achillis to the anterior aspect of the 
joint. The peroneii tendons and the lateral and capsular ligaments are 
divided, after which the foot may be displaced inward, exposing the 
joint, the ligament between the astragalus and the os calcis having 
been separated, the bone may be removed with a little manipulation ; 
after which all the diseased tissue in the soft parts and in the bone 
must be removed thoroughly. If the disease has not extended to the 
tarsus, and if it seems to have been completely removed, the wound 
may be closed after the peroneii tendons are sutured, but in most cases 
it should be packed, for a time, with gauze. The after-treatment is 
conducted as if the operation had not been performed ; support and 
fixation being continued until it is evident that the disease is cured. 

Removal of the astragalus does not interfere to a marked extent 
with the function of the foot, nor does it cause noticeable deformity. 
As a primary operation, permitting inspection and the opportunity for 
thorough removal of all disease in the neighboring parts, it should 



TUBERCULOUS DISEASE OF THE TARSUS. 341 

always be performed in preference to extensive gouging, which is, as a 
rule, of little avail. 

Prognosis. — Disease at the ankle is not only less common but it is 
less dangerous than that of the larger joints, because it is remote from 
important structures and because there is less opportunity for the 
burrowing of infected abscesses. The duration of the disease here, is, 
as a rule, shorter than at the knee or hip, and the final results in child- 
hood, are almost always excellent. Often free motion is retained, and 
even if the astragalus be fixed by disease, the mobility in the other 
joints of the foot is sufficient to compensate very effectively for the 
anchylosis. Shortening of the limb is of comparatively little conse- 
quence. It is not often more than an inch, and it may be absent. 
The growth of the foot is retarded partly from disease, and partly 
because of the destructive effect of the disease upon the tarsal bones. 

In the 30 cases reported by Gibney, treated expectantly, in which 
the mechanical treatment was far from effective, 6. patients recovered 
with normal motion ; 11 with practically normal function. In 7 there 
was good motion. In 6 there was anchylosis, and in 3 persistent 
valgus. In all, the limb was efficient. In 20 instances there was no 
limp, and in but one case was it marked. In no instance was a 
crutch, cane or other support used. The average duration of the dis- 
ease was 3 years and 3 months, a minimum of 1 year, a maximum of 
6 years. There were 2 deaths, of which but 1 was dependent upon 
the disease, septicaemia being the cause assigned, though it is stated that 
practically all the bones of the tarsus were involved. In this case 
amputation was evidently indicated. 



Tuberculous Disease of the Tarsus. 

Tuberculous disease of the joints of the foot, not involving the 
ankle, is not uncommon. 

In 386 of the 704 cases reported by Hahn, the disease was limited 
to the foot. In 141 cases the medio-tarsal joint was involved, in 51 
of these the disease was confined to this joint ; in 46 the ankle was 
involved ; in 29 the disease extended forward to the tarso-metatarsal 
articulation, and in 16 the three joints were diseased. In 78 cases 
the tarso-metatarsal joint was involved, in 33 of which the disease did 
not extend beyond this articulation. 

Disease of Individual Boxes. — In these cases the distribution 
was as follows : 

The astragalus 170 ; disease confined to the single boue in 8 

The calcaneus 200; " " " " " " 87 

The cuboid 116; " " " " " " 18 

Thescaphoid 82; " " " " " " 2 

The cuneiform bones.. 86; " " " " " " 8 

Metatarsal bones 45 ; in one-half of these the disease was of 

the 1st metatarsal, either alone or in connection with the adjoining 
cuneiform bone or phalanx. 



342 DISEASES AND INJURIES OF THE ANKLE JOINT. 

In a total of 1,231 cases, including these and others reported by 
Audry, 1 Koenig, 2 Mondan, 3 Munch, 4 Spengler, 5 Yallas, 6 Czerny 7 and 
Dumont, 8 the relative frequency of the disease in the bones of the foot 
and ankle appeared to be as follows : 

Malleoli 96, 7.7percent. Scaphoid 110, 8.9percent. 

Astragalus 291,23.6 " Cuneiform bones 109, 8.8 " 

Calcaneus 339, 25.9 " Metatarsus 110, 8.9 " 

Cuboid 154, 12.5 " Phalanges 22, 1.7 " 

Primary Disease of the Astragalo-scaphoid Joint. — In dis- 
ease at this point the swelling is localized in front of the ankle on the 
inner side of the foot. Adduction is restricted and the foot is often 
fixed in an attitude of persistent abduction. 

Disease of other bones of the tarsus is indicated by the local swelling 
and sensitiveness. The disease sometimes involves the shaft of a meta- 
tarsal bone, or one of the phalanges, causing expansion and destruction, 
" spina ventosa." (See page 356.) 

Treatment of Tarsal Disease. — Disease of the tarsus shows a 
marked tendency to extend from one bone to another until the entire 
foot is involved. Consequently if an early diagnosis is made of a dis- 
tinctly localized process, prompt removal of the diseased bone is indi- 
cated. But in most instances the disease is too extensive to permit of 
its radical removal. In such cases operative intervention is contra- 
indicated, and the treatment by protection, similar to that employed in 
disease of the ankle, is indicated. In childhood the prognosis is very 
good even when the disease is extensive, but in adult life amputation 
of the foot may be advisable, especially if there be co-existent disease 
of the lungs. 

Sprain of the Ankle. 

The ankle is, from its position, especially liable to injury, in fact 
the term " sprain " is popularly associated with this joint. 

A sprain is most often caused by an unguarded movement, by which 
the foot is turned suddenly inward or outward, with sufficient force to 
rupture some of the fibers of the muscles, to strain tendons and tendon 
sheaths and even to rupture ligaments. If the foot is twisted inward, 
the injury is most marked on the outer side of the joint ; if outward, 
on the inner side of the ankle. In the slighter degrees of sprain, the 
injury may be confined to the tissues about the joint, but in most in- 
stances there is effusion within the capsule, even hemorrhage when the 
injury has been severe. 

Symptoms. — The immediate symptoms of sprain are pain, often in- 
tense, of a throbbing character, swelling, heat and in many instances, 

lEevue de Chir., 1891. 5 Ibid., Bd. 44, 1897. 

2 Schmidt's Jahrb., Bd. 204, 1884. 6 Deutsche Chir., L. 66. 

3 Deutsche Chir., L. 66. 7 Volk. S. klin., V., No. 76. 

4 Deutsche Zeits. f. Chir., Bd. 11, 1879. 8 Deutsche Zeits. f. Chir., Bd. 17, 1882. 



SPRATS OF THE ANKLE. 343 

discoloration of the surrounding parts, even extending over the leg 
and foot. 

Treatment. — If an opportunity for immediate treatment is offered, 
the swelling and the effusion of blood may be restrained by the appli- 
cation of elastic stockinette bandages, from the toes to the knee. As 
much compression is exercised as the comfort of the patient will allow, 
and the bandage should be made sufficiently thick to prevent painful 
motion. If the injury has been severe and if the part is very sensi- 
tive to motion or jar, the joint having been protected with cotton may 
be fixed in a light plaster bandage. This may be cut down the front 
to allow for daily massage of the foot, ankle and leg which is of great 
service in hastening the absorption of the effusion. 

The use of hot air, hot and cold water and static electricity, and the 
like, are of service also in relieving the discomfort and especially in 
stimulating the circulation of the blood, upon which repair depends. 

Fig. 237. 




Adhesive plaster strapping applied for sprain of the ankle. 

By far the most effective treatment during the stage of recovery and 
as an immediate application for sprains of slighter degree, is the ad- 
hesive plaster strapping which has been popularized by Gibney. The 
plaster may be applied in a variety of ways ; a satisfactory method is 
as follows. 

One end of a strip of adhesive plaster about three feet long and 
three inches wide, is applied to the lateral aspect of the leg just below 
the knee joint ; it is carried down the side of the leg over the malleolus, 
beneath the heel and arch, and up the other side to a point opposite 
the beginning, where it is fixed by a circular band about the calf. If 
the sprain is of the outer side of the ankle, sufficient tension is made 
upon the outer half of the plaster to hold the foot slightly abducted. 
If, as is more common, the sprain is of the inner side, the inner half is 
drawn firmly beneath the arch, carrying the foot toward inversion so 
that all strain may be removed from the sensitive part. This band of 



344 



DISEASES AND INJURIES OF THE ANKLE JOINT. 



plaster is reinforced by one or more so that the lateral aspect of the 
ankle is completely covered. And in addition the entire ankle, with 
the exception of the heel, is then enclosed with narrow overlapping 
strips, which cover all the tissues, well beyond the sensitive area. The 
foot and leg are then bandaged to assure the adhesion of the plaster. 
When the joint is firmly held by the supporting plaster, the patient 
can, as a rule, walk with comfort ; and he is encouraged to do so, for 
functional use, provided it does not cause additional injury, is the most 
effective stimulant of the circulation ; thus the patient applying, as it 
were, an automatic massage, cures himself. 

As the swelling subsides the plaster strapping wrinkles, and it must 
be renewed, about three applications being required as a rule, the last 
of which is allowed to remain until all of the symptoms have disap- 
peared. It is perhaps needless to state that a preliminary shaving of 
the part will add somewhat to the comfort of the patient. Gibney ad- 



Fig. 238. 




The stockinette baudage. 

vises the use of narrow, overlapping strips and does not cover the front 
of the ankle ; the manner of application is, however, of little impor- 
tance provided that the sensitive part is efficiently supported and com- 
pressed. 

Chronic Sprain. — A chronic sprain may be the result of an inef- 
ficiently treated acute injury, in which an improper attitude originally 
assumed to spare the sensitive part, finally becomes habitual. In other 
instances, persistent disability may be the result of fixation of the joint 
for too long a time in splints. Such disuse causes atrophy of the muscles, 
while the effused material within and without the joint remains because 
of the imperfect circulation. The same disability may follow simple 
disuse of the injured part. It is more often observed in nervous indi- 
viduals who exaggerate the importance of the injury and the discomfort 
that it causes. In such cases the limb may be discolored by venous 
congestion, the foot may be oedematous and the movements may be 
limited by adhesions or by muscular adaptation to the habitual attitude. 



TENO-SYNO VITIS. 



345 



Fig. 239. 



Iii other instances the original injury may have caused a slight sub- 
luxation of the astragalus, sufficient to throw the foot into an attitude of 
abduction, in which it has become fixed by the secondary changes in the 
muscles and ligaments. In some cases of this class the original sprain 
was at the medio-tarsal or at the sub-astragaloid joint, and its eifect 
has been a traumatic weak foot. Finally, many of the so-called 
sprains of the ankle are simply injuries of a weak foot and are ex- 
amples of the rigid or inflamed weak or flat foot. (See the Weak Foot.) 

Treatment. — Treatment must be 
conducted with the aim of restoring the 
normal range of motion and so support- 
ing the part that normal functional use 
may be permitted. In many instances 
when adhesions have formed, and when 
the foot is persistently held in an ab- 
normal attitude, forcible manipulation 
under anaesthesia may be required as a 
preliminary treatment followed by fixa- 
tion for a time in a plaster bandage, in 
the attitude directly opposed to that 
which had been habitual. And as in 
this class of cases the habitual attitude 
is usually one of equino-valgus, the 
foot should be fixed for a time in a 
plaster bandage in a position of extreme 
varus, and upon it the patient is en- 
couraged to bear his weight both in 
standing and walking. When all dis- 
comfort has disappeared, a support, 
usually a light leg brace to prevent 
lateral motion, and if the arch is de- 
pressed a foot plate also, should be worn 
for a time. The most effective curative 
agent is functional use, but massage, 
hot air, passive manipulation and exer- 
cises are of service also. 

Injuries of this class are very amen- 
able to treatment, conducted with the 
aim of restoring normal function, when 
proper support is provided during the 
period of pain and weakness. 

Teno-Synovitis. 

The sheaths of the tendons about 
the ankle joint, if involved in a sprain 
of the ankle, may cause persistent in- ankS'Ld'Ky^ me'S^ of Z 

tendons beneath it artificially distended. 




terference with function ; or strain of 



(Testut.) (From Gerrish's Anatomy.) 



346 



DISEASES AND INJURIES OF THE ANKIE JOINT. 




The internal annular ligament of the ankle and the arti- 
ficially distended synovial membranes of the tendons which 
it confines. (Testut.) (From Gerrish's Anatomy.) 



a tendon and of its sheath may cause symptoms of disability when the 
joint is uninjured. The symptoms of acute teno-synovitis are discom- 
fort on motion of the af- 
Fig. 240. fected tendon and this 

motion may be accom- 
panied by a peculiar creak- 
ing which is apparent on 
palpation. In many in- 
stances there is slight local 
swelling and sensitiveness 
to pressure about the af- 
fected part, and the general 
movements of the foot that 
call the muscle into action 
are painful. 

The arrangement of the 
tendon sheaths should be 
borne in mind. At the 
ankle joint all the tendons 
are provided with sheaths ; 
on the front of the foot are 
three — the sheath of the 
tibialis anticus, which ex- 
tends from a point about two inches above the extremity of the malleo- 
lus to the scaphoid bone (Fig. 239); that of the extensor longus pollicis, 
from the annular ligament to 
the head of the first metatarsal, 
and the common sheath for the 
extensor communis digitorum 
extending from a point about 
half an inch above the malleoli 
to about one inch below the 
annular ligament. Behind the 
internal malleolus are the com- 
mon sheaths of the tibialis 
posticus and flexor longus digi- 
torum, beginning about an inch 
above the extremity of the 
malleolus and extending to the 
astragalo - scaphoid junction 
and that of the flexor longus 
pollicis of about the same ex- 
tent, (Fig. 240.) Behind the 
outer malleolus is the sheath of 
the two peroneii, beginning one 
inch above the malleolus, divid- 
ing into two portions for the 
two tendons and ending just behind the tuberosity of the fifth metatarsal 
bone. (Fig. 241.) 




The external annular ligament of the ankle and the 
artificially distended synovial membrane of the ten- 
dons which it confines. (Testut.) (From Gerrish's 
Anatomy.) 



OTHER AFFECTIONS OF THE ANKLE JOINT. 347 

Treatment. — Simple traumatic tenosynovitis should be treated by 
rest and by compression. An effective treatment is strapping by ad- 
hesive plaster, so applied as to prevent the movements of the foot 
that cause discomfort. In more painful and persistent cases the use of 
a plaster bandage to assure absolute rest may be necessary. Cautery 
applied over the affected part is of service. Chronic teno-synovitis 
may follow injury or it may be the result of gonorrhoea or other infec- 
tious disease. In chronic cases when the palliative treatment is inef- 
fective, thorough removal of the affected sheath is indicated. 

Tuberculous Teno-synovitis. — A persistent and increasing swell- 
ing of a tendon sheath always suggests tuberculous disease. In such 
instances the sac is thickened and often contains the so-called rice 
bodies. Prompt and complete removal of the diseased sheath is indi- 
cated and by this means a permanent cure may be attained in most 
instances. 

Other Affections of the Ankle Joint. 

The ankle joint may be the seat of an infectious arthritis ; it may 
be involved in an osteomyelitis of the tibia. It may be one of the 
joints affected in chronic rheumatism or rheumatoid arthritis, and oc- 
casionally Charcot's disease may appear in this situation. The princi- 
ples of the treatment of these affections have been indicated elsewhere. 



CHAPTER XII. 

DISEASES AND INJURIES OF THE ARTICULATIONS 
OF THE UPPER EXTREMITY. 

Tuberculous Disease of the Shoulder Joint. 

Disease of the shoulder is very uncommon in childhood. In a 
total of 453 cases of tuberculous disease treated at the Vanderbilt 
Clinic 210 were cases of Pott's disease. In 6 of the remaining 243 
cases, the disease was of the shoulder joint (2.5 per cent.). 

In 1,883 consecutive cases of joint disease — Pott's disease beiug 
excluded — treated in the Out-patient Department of the Hospital for 
Ruptured and Crippled during the past five years, the shoulder joint was 
involved in 38 instances (2 per cent.). In 1,900 cases of joint disease 
treated at Billroth's Clinic, the shoulder was involved in 14, or less 
than 1 per cent. 

Fig. 242. 



\ 

} 



Section of the shoulder joint, in childhood. (Schuchardt. ) 

Pathology. — The disease usually begins in the head of the humerus. 
In 32 observations on adults recorded by Mondan and Andry, 1 the 
primary disease was of the head of the humerus in 23 cases, of the 
humerus and scapula in 4, of the scapula alone in 1 and in 3 instances 
it appeared to be primarily synovial. 

In the majority of cases abscess forms and comes to the surface near 
the insertion of the deltoid muscles. In advanced cases the tissues of 
the axilla and of the adjoining thorax may be infiltrated and perforated 
by numerous sinuses. In other instances the disease is of the form 

1 Revue deChir., 1892. 



2 years 


old 


3 " 


u 


4 " 


u 


5 " 


it 


6 " 


a 


7 " 


it 


8 " 


it 


9 " 


a 


10 " 


a 


11 " 


a 


12 " 


tt 



SYMPTOMS. 349 

called caries sicca, in which there is no swelling, bat progressive destruc- 
tion of the head of the humerus by granulation tissue. This form is 
characterized by extreme muscular atrophy and by practical anchylosis. 

Statistics. 

Age at Incipiency of Disease at the Shoulder Joint in 62 Con- 
secutive Cases Treated at the Hospital for Rup- 
tured and Crippled. 

1 year or less 1 13 years old 3 

6 15 " " 2 

1 18 " " 3 

3 19 " " 5 

3 20 " " 4 

1 23 " " 1 

3 26 " " 2 

4 27 " " 1 

6 34 " " 1 

1 48 " " 1 

5 56 l: " 1 

4 Total .62 

Males 38, females 24 ; right 35, left 27. 

Townsend ] made a detailed report on 2 1 cases treated at the Hos- 
pital for Ruptured and Crippled during the years 1889 to 1893. Ten 
of these were less than ten years of age, 7 were between ten and twenty, 
and 4 were more than twenty. The youngest patient was three and 
a-half and the age of the oldest was thirty-five years. In 5 cases the 
disease was secondary to disease of other parts ; in one case to Pott's 
disease, in 2 to hip disease and in 2 to disease of the knee joint. 

Symptoms. — The history of the case will show the persistent and 
progressive character of the disability, but the symptoms, characteristic 
of tuberculous disease, are far less marked at the shoulder than at 
other joints. This is explained by the fact that the upper extremity is 
not subjected to the strain of weight-bearing and because the mobility 
of the scapula upon the thorax lessens the injury caused by unguarded 
movements of the arm. This double joint at the shoulder masks the 
interference with the function of the joint, and even when absolute 
anchylosis is present the patient may think that the movements are but 
moderately restricted. Finally, the traumatism caused by over-use may 
be lessened by the voluntary restraint that the patient may exercise 
upon motion at this joint, without greatly inconveniencing himself. 

The symptoms of the disease may be classified as pain, sensitiveness, 
restriction of motion, atrophy. 

The pain is usually of a dull aching character with occasional neu- 
ralgic pain referred to the elbow and arm. The discomfort is increased 
by movements that pass beyond the limits allowed by the mobility of 
the scapula, especially on attempting to rotate the humerus, as in 
clothing oneself or brushing the hair. The joint is sensitive to pressure, 
thus the patient finds that he can not lie on the affected side at night. 
1 Trans. Am. Orth. Ass'n, Vol. VII. 



350 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. 

On physical examination the limitation of motion caused by muscular 
spasm will be evident when the scapula is fixed, so that movement of the 
joint can be tested. Normally the range between adduction and abduc- 
tion is about 90 degrees, and between flexion and extension it is some- 
what less than this. 

Pressure upon the head of the humerus usually causes pain, and in 
many instances local heat and swelling are present. The atrophy of 
the shoulder muscles is often extreme and that of the other muscles of 
the limb is well marked. 

As has been stated, abscess is a common accompaniment of the dis- 
ease, and in such cases the tissues about the joint are swollen and in- 
filtrated. In other instances there is progressive destruction of the 
head of the humerus without abscess formation (Caries sicca). In 
cases of this type the flattening of the shoulder may be so extreme as 
to be mistaken for sub-coracoid dislocation. 

Treatment. — The treatment of the disease here as elsewhere is rest. 
To assure absolute functional rest the wrist should be attached to the 
neck by a sling, the elbow being flexed to an acute angle ; the arm is 
then fixed to the thorax by a bandage and all the clothing, including 
the shirt, is placed outside the aflected part. Local rest and compres- 
sion may be still further assured by strips of adhesive plaster applied 
over the shoulder and extending to the back and chest ; or a shoulder 
cap of leather or plaster may be employed. This method of fixing the 
arm is the only one that assures continuous rest, as a change of the 
clothing necessitates movement of the joint, which causes discomfort 
and retards the cure. During the acute phases of the disease, the arm 
may be supported in the attitude of extreme abduction by means of a 
triangular splint or pad. This position is often that of greatest com- 
fort to the patient. Direct traction is not often employed, as support 
of the pendant limb is usually preferred by the patient. 

Operative Treatment. — If the focus of disease seems to be localized, 
an exploratory operation for its early removal may be indicated. Ex- 
cision of the joint in the adult cases, or arthrectomy in younger sub- 
jects, may be advisable when suppuration is persistent or when for 
other reasons it may seem best to attempt to remove the diseased area. 

Prognosis. — The duration of the disease appears to be from two to 
five years. The death rate is higher than in disease of the joints of the 
lower extremity, because a larger proportion of the patients are adults 
and in this class tuberculosis of the lungs is not an infrequent compli- 
cation. 

It is impossible to speak positively of the results of the conserva- 
tive treatment of disease of the shoulder. The disease is uncommon 
and protection is almost never applied in the early stage, nor efficiently 
or persistently employed to the end. The ordinary result is therefore 
anchylosis, usually of the fibrous rather than of the bony variety. 

If the disease appears in early life the growth of the limb may be 
seriously interfered with ; an inch or more of shortening from this cause 
is not uncommon. 



TUBERCULOUS DISEASE OF THE ELBOW JOINT 351 

Tuberculous Disease of the Elbow Joint. 

Tuberculous disease of the elbow joint is the fourth in order of fre- 
quency, preceding the shoulder and the wrist. Of 1,883 consecutive 
cases of joint disease treated at the Hospital for Ruptured and Crippled, 
56 were of the elbow. 

Pathology. — The primary disease is in most instances osteal, as in 
92.8 percent, of the cases investigated by Scheimpflug, 44 in number. 1 
The original focus of infection is somewhat more often of the ulna than 
of the humerus. Of the ulna the olecranon process, and of the humerus 
the external condyle, appear to be the points of election. Disease of the 
head of the radius is comparatively infrequent. In 119 cases reported 
by Oilier, the olecranon was involved in 73, the humerus in 33 and 
the radius in 12 instances. 2 And in the cases investigated by Kummer, 3 
and Middledorpt, 4 the ulna was more often the seat of the primary 
disease than was the humerus, but in 81 cases treated in Koenig's 
clinic the primary disease was of the humerus in 43, of the olecranon 
in 36 and of the radius in 2 instances. 5 

Statistics. 

Age at Incipiency of Disease at the Elbow Joint in 59 Consecu- 
tive Cases Treated at the Hospital for Kuptured 
and Crippled. 

1 year or less 2 11 years old 1 



2 years old 5 13 

' 8 14 

' 5 15 

1 5 17 

< 4 19 

' 8 21 

1 1 23 

! 2 25 

' 5 29 



3 


it 


4 


■ii 


5 


a 


6 


a 


7 


it 


8 


a 


9 


n 


10 


a 



a 
it 

" 2 

" ._L 

Total «.59 



Males 28, females 31 ; right 27, left 32. 

Symptoms. — The symptoms are those of a chronic, persistent, de- 
structive disease. Pain, local sensitiveness and swelling, stiffness, de- 
formity, atrophy. 

The pain is usually localized at the elbow. It is increased by sud- 
den movements, and as the bones are so superficial there is usually 
local sensitiveness to pressure, most marked over the seat of the dis- 
ease. In the early stage the swelling is slight and it is of the peculiar 
elastic character due to thickening of the tissue, rather than to effusion 
within the capsule, but as the disease progresses the joint assumes the 
peculiar spindle shape characteristic of white swelling. The degree 
of elevation of the local temperature depends upon the activity of the 

1 Festschrift fur Billroth, 1892. 

2 Karewski, Chir. Krank. des Kindersalters, p. 268. 
3 Deutsche Zeits. f. Chir., Bd. 27. 

* Archiv f. Klin. Chir., Bd. 33. 

5 Koenig, Lehrbuch Spec. Chir., Berlin, 1900. 



352 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. . 



Fig. 243. 



disease. The most important physical sign is the restriction of motion 
due to the characteristic muscular spasm which becomes evident when 
the limit of painless motion is passed. The limitation of extension 
and flexion gradually increases and finally the limb becomes fixed in 
an attitude midway between flexion and extension, Avith the forearm 
in an attitude midway between pronation and supination. This is the 

characteristic deformity of the 
disease. 

Atrophy of the muscles of the 
arm and forearm is present, cor- 
responding to the intensity and 
duration of the disease and to the 
functional disability of the joint. 
Treatment. — The treatment 
here, as elsewhere, consists essen- 
tially in placing the joint at rest 
in the attitude at which anchylo- 
sis or limitation of motion will 
least inconvenience the patient, 
and at the elbow joint, this is 
practically at right-angular flex- 
ion. (Fig. 244.) 

In the treatment of young 
children the wrist may be at- 
tached closely to the neck by 
means of a sling, with the elbow 
at an acute angle (the Thomas 
method) within the clothing. Or 
a light plaster bandage may be 
used to fix the joint, together 
with the sling. This enables the 
patient to dress himself without 
moving the part and it protects 
the joint from injury. Other 
forms of splints may be employed, but the plaster bandage answers 
every purpose. It should, of course, extend from the axilla to the 
hand, and in sensitive cases it may include the hand also. 

Reduction of Deformity. — In many instances the arm is fixed in 
the semi-extended attitude when the patient is brought for treatment. 
In this class of cases a simple and effective means of reducing deform- 
ity is that suggested by Thomas. When it is impossible to bring the 
wrist to the neck, one bends the neck toward the wrist and attaches 
the two by a bandage that the patient is unable to remove. From this 
uncomfortable attitude the patient can free himself only by drawing the 
arm toward the neck and thus reducing the deformity. At the next 
visit the same procedure is repeated, until finally the elbow is flexed to 
the required degree. A permanent sling may be constructed of a leather 
wrist band and a tube of leather to pass about the neck, through which 




Tuberculous disease of the elbow joint. 



OPERATIVE TREATMENT 



353 



the bandage may be drawn ; thus the pressure on the wrist and neck 
may be lessened. In the very resistant cases reduction of deformity 
under anaesthesia may be required, but this is not often necessary/ 

Prognosis. — If the case is treated at an early stage the prognosis in 
childhood is good. The duration of treatment may be estimated at 
two years or more and retention of a fair range of motion may be ex- 
pected. Anchylosis in the right-angled position does not, however, 
seriously inconvenience the patient, provided the cure is absolute. 
The loss of growth is less than when the epiphysis at the shoulder is 
destroyed and the final disproportion in size depends, of course, upon 
the age of the patient and upon the degree of function that is preserved. 

Fig. 244. 




Tuberculous disease of the elbow joint, the stage of recovery. 



Operative Treatment. — In some instances it is possible to remove 
small foci of disease from the humerus, or from the ulna, before the 
joint is involved. The position of the disease may be indicated by 
sensitiveness or swelling and in older subjects a Roentgen picture may 
demonstrate its position accurately. 

Excision of the Elbow. — Excision is often advisable in adoles- 
cent or adult life, because by this procedure, in most instances, the 
disease may be cured in a definite time and because a movable joint 
may be assured. 

Oschman has recently investigated the final results of the operation 
23 



354 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY; 

performed on this class at Kocher's 1 clinic at Berne, 1872-1897. In 
forty of forty-five cases the operation was performed for tuberculous 
disease. There were no deaths referable to the operation. Of the 
entire number of cases, fifteen were dead, but eleven of these survived 
the operation for from five to twenty years. Eight of the deaths were 
due to tuberculosis, two to other causes and in five the cause of death 
was unknown. In ninety-six per cent, of the cases the local disease was 
cured. In sixty-eight per cent, of the cases the patients were able to 
use the limb at hard labor and in the others it was efficient for light 
work. In six cases there was subluxation or luxation, in five the joint 
was not firm. In fifty-nine per cent, the motions were practically 
normal. In eleven per cent, the joint was anchylosed. The Kocher 
method of exploring and excising the joint which was employed in 
the majority of these cases has the advantage of sparing the muscu- 
lar attachments and affording an opportunity for inspection of the 
interior. 

The incision begins upon the outer aspect of the humerus, from 
three to six cm. above the line of the joint and is carried directly 
downward over the head of the radius, passing in the interval between 
the extensor muscles of the arm in front and the anconeus behind. It 
is then carried inward and downward across the back of the forearm 
to a point from four to six cm. below the tip of the olecranon, then 
upward for two cm. on the inner side of the ulna. Thus the mus- 
cular insertions are spared. The olecranon process is then divided 
and turned upward and the joint is exposed. If a complete excision 
is to be performed the olecranon is separated from its muscular at- 
tachments and the periosteum if possible. The part must be sup- 
ported until the repair is complete, and in the after-treatment lateral 
support by means of a light jointed brace will add to the comfort of 
the patient and prevent distortion. 



Tuberculous Disease of the Wrist Joint. 

Disease of the wrist joint is very uncommon in childhood. In a 
total of 3,105 cases of tuberculous disease treated in the Out-patient 
Department of the Hospital for Ruptured and Crippled during the past 
five years, 98 were of the upper extremity and in but four of these was 
the wrist joint involved. Of 43 cases in which the joint was resected 
by Oilier, the youngest patient was thirteen years of age. 

Of 990 cases of disease of the joints in childhood, reported by 
Karewski, the wrist was involved in 31. 2 

Disease of the wrist in older subjects is less infrequent, although at 
all ages it is rare as compared with disease in other joints. Tubercu- 
lous disease of the metacarpus and phalanges (spina ventosa), is, how- 
ever far more common. 

1 Archiv f. Klin. Chir., Bd. 60, H. 2, 1900. 
2 Chir. Krank. des Kindersalters, Berlin, 1894. 



TUBERCULOUS DISEASE OF THE WRIST JOINT 



355 



Age at Incipiency of Disease at the Wrist Joint in 18 Consecu- 
tive Cases Treated at the Hospital for Ruptured 
and Crippled. 

2 years old 1 19 years old 2 



6 


n i 




.... 1 


20 


n 


i i 


2 


9 


U t 




.... 1 


25 


i i 


a 


2 


12 


it i 




.... 2 


26 


it 


it 


2 


14 


U i 




.... 1 


27 


1 1 


t t 


.. 1 


16 


it i 




.... 2 






Total 


18 


17 


a i 




.... 1 














Males 11, 


females 7 ; 


right 


12, left 6. 





Symptoms. — The symptoms of tuberculous disease of the wrist are 
as in other situations pain, local swelling and sensitiveness, limitation 
of motion, caused by muscular spasm and atrophy. In advanced cases 
the hand is usually flexed somewhat upon the arm. 

Treatment. — The treatment of this, as of other joints, is functional 
rest, with support in the attitude in which anchylosis or limitation of 

Fig. 245. 




Tuberculous disease of the carpus. 

motion will cause the least inconvenience. A light plaster bandage 
extending from the elbow to the tips of the fingers, applied over a 
flannel bandage drawn as tight as the comfort of the patient will per- 
mit, is a satisfactory support ; or a leather splint or other form of ap- 
pliance may be used. The hand should be held in an attitude of 
moderate dorsal flexion, which will permit the flexor muscles to close 
the fingers easily if the wrist becomes fixed by the disease. If flexion 
deformity is present it should be corrected by degrees, with each appli- 
cation of the bandage, until the desired attitude is attained. (Fig. 247.) 
The flannel bandage exercises a certain amount of compression upon the 
wrist which seems to be of benefit, and in certain instances, this com- 
pression and fixation may be still further increased by the application 
of adhesive plaster. When the disease of the joint is quiescent, or in 
the stage of recovery, the bandage or splint may be shortened to allow 
the patient to use the fingers. 

Prognosis. — The prognosis as regards function in cases treated 
promptly in childhood should be good. In the adult cases, wrist-joint 



356 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. ' 

disease seems to be very often complicated by disease of the lungs, 
thus the prognosis as to life is often bad. In this class of cases early 
excision is usually recommended, with amputation as a final resort. 

Fig. 246. 




Tuberculous disease of the left wrist joint. The irregularity and the diminished size of the carpal 
bones indicate the extent of the destructive process. The patient, the mother of the child (Figs. 
10-11) with Pott's disease, died within a year of tuberculosis of the lungs. 



Spina Ventosa. 

Central disease of the long bones of the foot and hand is the most 
common form of tuberculous osteomyelitis. The marrow is the seat 
of the disease and caseous degeneration is common. While the corti- 
cal substance is destroyed from within it is often replaced in part by 
a formation of periosteal bone from without, which in turn may be 
destroyed by the advancing disease. In the early cases the affected 
bone is enlarged, spindle-shaped, and is somewhat sensitive to pressure. 
At this stage repair may take place with but little ultimate change 
from the normal, but in many instances the bone is perforated and in 
part destroyed, the neighboring joint is involved and the finger be- 
comes stunted and distorted. 

In 159 cases tabulated by Karewski, 1 the metacarpal bones were 
diseased in 65 instances — the phalanges in 57 — the metatarsal bones 
in 29 — the phalanges of the toes in 8. In a number of instances sev- 

1 Chir. Krank. des Kindersalters, Berlin, 1894. 



SPINA VENTOSA. 



357 



eral of the bones and larger joints were involved (159 cases in 135 
patients). 

The disease is more common in the early years of life, 84 of the 135 
patients being four years of age or less, 38 of these being less than two. 



Fig. 247 




Treatment of tuberculosis of the wrist joint by plaster of Paris, showing the proper attitude. 

Spina ventosa of the phalanges may be treated by rest and compres- 
sion, and both splinting and compression may be exercised by adhesive- 
plaster strapping. If the joint is involved, amputation of the finger 

Fig. 248. 




Tuberculous disease of the wrist and knee joints showing the characteristic deformities in 
neglected cases of a severe type. 

may be indicated because of the distortion and loss of growth that may 
be expected. Tuberculous disease, limited to a single bone of the car- 
pus, or metacarpus, may be treated by operative removal of the disease. 



358 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. 

Periarthritis of the Shoulder. 

Under the title of scapulohumeral periarthritis, Duplay l in 1872 
described a painful affection of the shoulder induced by traumatism, 
dependent upon an inflammation of the bursa lying between the del- 
toid and the supra- and infra-spinatus muscles and the coraco-acromial 
ligament. But under this title are now included a number of affections 
that cause similar symptoms in which it would appear that the interior 
of the joint is not involved. 

Symptoms. — In a typical case of so-called periarthritis, the patient 
complains of a dull pain about the joint and sensitiveness to pressure 
just below the acromion process or over the bicipital groove. The 
pain is increased by motion, particularly by abduction or by rota- 
tion of the arm. In mild cases, only extensive motion causes pain, 
but in most instances there is a constant sensation of discomfort which 
is increased to acute pain by sudden movements or jars. The part be- 
comes sensitive to pressure so that the patient avoids lying on the 
shoulder at night. In certain instances the pain may radiate down the 
arm and there may be weakness and numbness of the fingers. Grad- 
ually the passive movements of the joint are diminished in range, and 
atrophy of the shoulder muscles appears. 

These symptoms usually pass as rheumatism, but there is no fever, 
no involvement of other joints, no swelling, and, as a rule, no general 
sensitiveness to pressure, as is usual when the synovial membrane of 
the joint is affected. In certain instances these symptoms follow injury, 
or exposure to cold or they appear without apparent cause. In one 
class of cases the symptoms may be due to an inflammation of the sub- 
deltoid bursa, as in the cases originally described by Duplay ; in others 
to a tenosynovitis of the biceps tendon, that may extend to the sur- 
rounding parts. This is suggested by local sensitiveness at the bicipital 
groove, and by the creaking sensation at this point when the muscle 
is in use. Or the symptoms may be due to neuritis affecting the cir- 
cumflex nerves, as suggested by Amidon. 2 It is probable also that the 
nerves in the neighborhood of the joint may be secondarily implicated 
in an inflammation of bursse, or directly injured by the original trauma- 
tism, if such preceded the symptoms. It is also possible that the 
bursitis may have been a sequel of gonorrhoea or of other infectious 
disease. 

Treatment. — During the acute and painful stage the part should be 
kept at rest. Cautery may be applied and the joint should be enclosed 
in adhesive plaster strapping, and if the weight of the limb causes 
discomfort, it should be supported. In certain instances tension on 
the sensitive part may be relaxed by supporting the arm in an attitude 
of abduction. When the acute symptoms have subsided passive move- 
ments, massage and static electricity are of service. Voluntary exer- 
cises should be employed when they no longer aggravate the symptoms. 

1 Archiv Generale de Med., Paris, 1872. 

2 Am. Medico-Surg. Bull., March 21, 1896. 



SPRAIN OF THE WRIST. 359 

In the cases of long standing in which motion is very much restricted, 
apparently by adhesions without the joint, passive movements under 
anaesthesia may be of benefit. In such cases it may be well to sup- 
port the limb for a time in the abducted attitude to prevent the for- 
mation of the adhesions. Afterwards, passive motion, massage and 
exercises may be employed. If these cases are treated carefully in 
the early stage, recovery is usually rapid, but if neglected the symptoms 
may persist indefinitely. 

Chronic Bursitis. 

Chronic bursitis at the shoulder joint is comparatively infrequent. 
The bursse most often involved are the coracoid, the sub-scapular and 
the deltoid. Of these the last is the most often involved. Sixteen 
cases have been reported by Blauvelt, 1 and three others by Ehrhardt. 2 
The enlarged bursa forms a fluctuating swelling most evident on the 
anterior and outer aspect of the shoulder, the symptoms being discom- 
fort, weakness and limitation of motion of the arm. The disease is 
usually tuberculous in character and it should be treated by incision 
or by complete removal of the sac, if possible. 

Sprain of the Wrist. 

This is a very common accident. The most effective treatment is 
the adhesive-plaster strapping applied about the metacarpus, wrist and 
lower half of the arm. If the pain on motion is severe, sufficient 
plaster is applied to splint the part and to limit movement to the point 
of comfort. If the injury is of a slighter grade the compression and 
support of a single layer of plaster is usually sufficient. This dressing 
prevents injury and yet it allows a certain degree of functional use which 
is the most effective means of restoring a joint to its normal condition, 
by hastening the absorption of the effused material within and without 
the joint. 

Chronic Sprain. — Persistent weakness and stiffness may follow 
treatment of a sprain by splints, or when for any reason disuse of 
function has been long continued. In many instances, however, 
the sprain was in reality a fracture or displacement. All chronic 
sprains, therefore, should be examined by means of the X-ray in 
order that the presence or absence of more extensive injury may be 
determined. 

The treatment is similar to that of the acute sprain, protection from 
injury, and functional use to the extent of which the part is capable. 
With this, massage, hot air and electricity or other form of local stimu- 
lation may be employed with advantage. The same treatment is indi- 
cated when the joint is stiff and painful as the result of rheumatism or 
other inflammation, provided the stage of recovery has been reached. 

1 Beitrage zur Klin. Chir., Bd. 22. 
2 Archivf. Klin. Chir., Bd. 60, 1900. 



360 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. 

Acute Teno -Synovitis. 

Tenosynovitis is common at the wrist joint. It is usually induced by 
strain or over-use of a muscle or set of muscles. Movements of the 
muscles that are involved cause discomfort and there is usually local 
sensitiveness and a creaking sensation on palpation over the affected 
tendon sheath. The adhesive-plaster strapping, so applied as to exert 
compression and to prevent the motion that causes discomfort, is the 
most effective treatment. 

Chronic teno-synovitis, causing progressive enlargement of a tendon 
sheath with accompanying symptoms of weakness and discomfort, is 
usually tuberculous in character. In such cases the diseased part 
should be promptly removed. 



CHAPTER XIII. 

CONGENITAL AND ACQUIRED AFFECTIONS LEADING 
TO GENERAL DISTORTIONS. 

Rhachitis. 

Synonym . — Rickets. 

Rhachitis is a constitutional disease of infancy caused by defective 
nutrition, of which the most marked effect is distortion of the bones. 

Etiology. — The predisposing cause is constitutional weakness. This 
may be inherited, or it may be the direct effect of illness, but most 
often it is the result of improper hygienic surroundings, particularly 
lack of sunlight, damp rooms, over-crowding and defective ventilation. 
The direct cause of the disease is improper nourishment. In most in- 
stances this is due to the substitution of artificial food for the mother's 
milk, in others to improper diet after the infant is weaned ; in rare 
cases it may be the result of prolonged lactation, or it may be caused 
by the defective quality of the mother's milk. The disease therefore 
begins usually between the ages of six and eighteen months, although 
it is by no means confined to these limits. In most instances improper 
surroundings and improper nourishment are combined in the causa- 
tion of the disease ; thus rhachitis is relatively common in large cities. 
At the Hospital for Ruptured and Crippled the most extreme cases 
are observed among the Italian and the colored children. The former 
are usually nursed but are improperly fed after weaning, while the 
latter, if nursed at all, are usually allowed a mixed diet even during 
the early months of life. 

Pathology. — The manifestations of a disease dependent upon im- 
paired nutrition are of course general in character. In rhachitis there 
is a mild degree of ansemia, and a general weakness and relaxation of 
the voluntary and involuntary muscles. As a result the circulation is 
impaired and the power of assimilation is diminished, thus congestion 
and enlargement of the internal organs, intestinal catarrh, bronchitis 
and the like, are common accompaniments of the disease. The most 
marked and characteristic changes are found in the bones ; these con- 
sist in a diminution of the earthy substances and in overgrowth of 
osteoid tissue. 

" The essential features of the morbid process are, first, an exagger- 
ation of the processes immediately preparatory to the development of 
true bone ; secondly, an imperfect conversion of this preparatory tissue 
into true bone ; and thirdly, a great irregularity of the whole process." 
(Erichsen.) 



362 



AFFECTIONS LEADING TO GENERAL DISTORTIONS. 



On section of a rhachitic bone it will be noted that the periosteum 
is increased in thickness, and is more or less adherent to the under- 
lying softened and spongy tissue. The medullary canal is enlarged 
and its contents are abnormally vascular. The epiphyseal cartilage, 
normally a thin bluish line, is much increased in thickness. It appears 
to be swollen and infiltrated, and it has lost its former translucency. 
Microscopical examination at this point, where growth is most active, 
shows marked irregularity in size and shape of the columns of carti- 
lage cells ; the zone of calcification is lacking or is ill-defined, and 
masses of cartilage cells are found unchanged in what should be the 

area of true bone. The same 
Fig. 249. irregularity of line and shape 

is observed in the medullary 
spaces of the newly formed 
osteoid tissue. 

As a direct result of the 
changes that have been de- 
scribed, the epiphyseal junc- 
tions are enlarged and the 
shafts of the bones are thick- 
ened by the formation of 
osteoid tissue beneath the 
periosteum. The indirect 
effects of the disease, and of 
the weakness that it causes, 
are deformities, the nature of 
which Avill be indicated under 
the heading of symptoms. 
The stage of weakness is 
followed by that of repair, 
which sometimes goes on 
with great rapidity ; the 
softened bones become ab- 
normally hard, "eburnated," 
and premature solidification 
at the epiphyseal junctions 
may be one of the more re- 
mote results of the disease, that accounts in part for the dwarfing of 
the stature, observed as one of the final results of severe rHachitis. 

Symptoms. — As the disease is the effect of imperfect assimilation 
its more pronounced symptoms are preceded by those of indigestion, 
such as flatulence, constipation and the like. Profuse perspiration, 
especially about the head, and restlessness at night are common symp- 
toms. Teething is often delayed or is irregular. The infant is slow 
in its movements and makes little effort to stand or to walk at the 
usual time, and if the disease is active, the affected parts may be sen- 
sitive to pressure. 

Deformities. — The deformities are in part due to the direct effect of 




General rhachitic deformities, showing distortions 
of the arms. 



DEFORMITIES OF RHACHITIS. 



363 



the disease. One of the earliest and most constant evidences of rha- 
chitis is the enlargement about the epiphyses, an enlargement caused 
in part by the direct hypertrophy, and in part by pressure upon the 
softened tissues. The enlargements at the junctions of the ribs and the 
costal cartilages, the "rhachitic rosary," "and at the wrists and ankles, 
" ^2E£i*L££^ TS >" are a l most invariably present in well-marked cases. 
The more general distortions are in part the effect of atmospheric pres- 

Fig. 250. 




Chondrodystrophia of slight degree contrasted with ordinary rhachitis, in sisters. 1. Chondro- 
dystrophia. Broad, short, very flexible hands, trunk disproportionately long— knock knees. Age 5% 
years, height 30% inches ; normal height 40 inches. 2. Rhachitis, bow legs, age 4 years ; height 32% 
inches ; normal height 36 inches. 



sure, in part the effect of the force of gravity and habitual postures, 
and in some instances muscular action or injury may deform the soft- 
ened bones. These deformities differ greatly according to the time of 
onset of the disease, and with its duration and severity. The head 
may^be long and oblong in shape, or rectangular, " caput quad- 
RATUM," and it sometimes presents prominences in the frontal and 
parietaL regions L due to thickening of the bones, and on the posterior 
aspect depressed and softened areas, " craniotabes." The fontanelles 



3()4 AFFECTIONS LEADING TO GENERAL DISTORTIONS. 

are abnormally large and they may remain open long after the usual 
time of closure. 

The thorax is compressed from side to side, the compression being 
most marked in the middle region where the ribs have the longest 
cartilages and the least direct support. As secondary results, the back 
of the chest is flattened and the sternum is thrust forward forming the 
pigeon breast. The lower ribs are everted to accommodate the dis- 
tended abdomen, " pot belly." In well-marked cases the rhachitic 
chest presents two distinct grooves, one transverse in the axillary line, 
u Harrison's groove/' and the other passing upward by the side of 
the rhachitic rosary. These deformities are in great degree caused by 
atmospheric pressure, but they are increased if the child assumes the 
sitting posture habitually. In this attitude the body is inclined for- 
ward, the clavicles are distorted and the spine is bent into a more or 
less rigid posterior curve, most marked in the lower dorsal and lumbar 
regions, the " rhachitic spine." Less often there may be a lateral 
deviation or scoliosis. 

The arms may be distorted by the efforts of the child to support the 
body in the sitting posture, or by active exertion, as in creeping. (Fig. 
249.) Occasionally the deformities may be localized at the elbows, and 
sufficiently marked to merit the name cubitus varus or valgus, cor- 
responding to genu valgum or varum ; or the principal distortion may 
be a dorsal convexity of the lower extremity of the radius. 

The bones of the lo wer_ extremity are often distorted, primarily by 
the habitual postures assumed in sitting or creeping and these defor- 
mities are usually exaggerated when the erect attitude is assumed. In 
some instances it would appear that the femoral necks are twisted back- 
wards somewhat ; this distortion may explain in part the limitation of 
inward rotation that is sometimes observed in rhachitic children. The 
changes in the pelvis are of special interest to the obstetrician. These 
are essentially anThcrease in the sacro- vertebral prominence, due to the 
forward and downward displacement of the sacrum, an abnormal ex- 
pansion of the ilia, caused by pressure of the abdominal contents and, 
in some instances, a decrease of the lateral diameter, an effect of the 
pressure of the femora upon the yielding bone. 

In the milder type of rhachitis in older children, who walk, the defor- 
mities are often confined to the trunk and lower extremities. In such 
cases, in addition to the changes in the bones, there is usually a promi- 
nent abdomen and increased lordosis, combined with slight habitual 
flexion of the thighs and lower legs, the " rhachitic attitude." 

If the disease is of sudden onset and is severe and general in its 
manifestations, it may be accompanied by pain, by sensitiveness of the 
affected bones and by such weakness of the lower extremities as may 
simulate paralysis, rhachitic pseudo-paralysis. 

It is probable, however, that the cases in which the pain is extreme, 
" acute rhachitis," are, in reality, scurvy or scurvy and rhachitis com- 
bined, scurvy rickets so-called. 

Ehachitis, as described, is the type ordinarily seen in hospital prac- 



TREATMENT. 365 

tice and its manifestations are unmistakable. In its milder form it is 
not particularly uncommon among the children of the well-to-do, whose 
hygienic surroundings are good. In such cases the most marked symp- 
tom is weakness. The child is often fat and well developed, although, 
as a rule, pale. The abdomen is somewhat enlarged and slight promi- 
nences at the epiphyseal junctions, particularly at the wrists, may be 
made out. The legs appear small in proportion to the body and the 
ligaments are lax, so that if the child stands the feet are flat and as- 
sume the attitude of valgus. In this class, in which the child is said 
to have weak ankles, Tmockjmee is common. 

The most common symptom then of mild rhachitis is the failure of 
the child to attempt to walk at the usual time, about sixteen months. 
If a child who is not ill and who has not suffered from exhausting dis- 
ease does not walk at two years of age, it is probably rhachitic. 

Prognosis. — The duration of the progressive stage of rhachitis de- 
pends, of course, upon the age of the patient and upon the treatment. 
In cases that are untreated and in which the predisposing causes con- 
tinue, the period of repair may be delayed for several years or longer, 
as shown by the fact that the child makes little eifort to stand ; but, 
in most instances, the rhachitic child begins to walk at some time dur- 
ing the third year and at this time the deformities of the lower ex- 
tremity, knock knee, bow leg, flat foot and the like, usually develop 
or become aggravated, while those of the upper extremity may become 
less noticeable. 

The deformities of rhachitis tend to disappear or to become less 
marked with growth ; the concavities of the distorted shafts are filled 
by accretions of periosteal bone, which is again absorbed from the in- 
terior as the medullary canal straightens itself. The thickened dia- 
physes and enlarged epiphyses become more symmetrical under the 
influences of rapid growth and increased functional activity, but traces 
of severe rhachitis always remain and many of the more noticeable and 
permanent distortions of the trunk and of the lower extremities are 
due to this cause. 

The prognosis as to the outgrowth of rhachitic deformities depends 
upon the duration and the severity of the disease and upon the func- 
tion of the deformed part. Rhachitic distortions of the arms almost 
always disappear. The rhachitic chest is rarely seen in the adoles- 
cent or adult. The rhachitic kyphosis is corrected or modified when 
the erect posture is assumed, but rhachitic, scoliosis, on the other hand, 
usually increases with the growth. Distortions of the lower extremi- 
ties may entirely disappear and in«lri6st cases they are less marked in 
the adult than in the child. Stunting of the growth is a constant 
effect of severe and prolonged rhachitis ; it depends in part upon the 
arrest of development during the active stage of disease and in part 
upon the changes in the bones that cause premature consolidation at 
the epiphyses. 

Treatment. — The treatment of rhachitis consists essentially in a re- 
versal of the conditions under which it developed. It is therefore die- 



366 AFFECTIONS LEADING TO GENERAL DISTORTIONS. 

tetic, hygienic and medicinal. Deformity, the effect of the disease, 
may be prevented by guarding the weakened bones from overstrain, or 
it may be remedied, if it be present, by manipulation or by mechanical 
or by operative treatment. 

The more detailed treatment of rhachitis may be found in works on 
Pediatrics. In general, the diet in the cases developing in early in- 
fancy should be of milk, especially modified according to the need of 
the patient. At a later time, corresponding to the normal period of 
weaning, the diet should be largely animal, to the exclusion of starchy 
food ; cream and fresh butter being especially valuable. 

The patient, protected by proper woolen underclothing, should pass 
as much time as possible in the open air and should sleep in a well- 
ventilated room. Daily salt baths are recommended for older children 
and regular massage of the extremities, and of the abdomen, should 
be employed. Medicinal treatment is of secondary importance. The 
bowels should be regulated and digestion should be aided by proper 
remedies. For anaemia, which is usually present, the syrup of the 
iodide of iron is of value ; cod-liver oil serves both as a food and 
medicine, when it is readily assimilated. It is unlikely that any drug 
has a very direct influence on the disease. Phosphorus in doses of 
1/200 to 1/100 of a grain is often given and is supposed to lessen the 
abnormal congestion of the bones, while the deficiency of lime salts 
may be supplied possibly, by the administration of lime in some form, 
the syrup of the lactophosphate of lime being a favorite prescription. 

The prevention of deformity, other than by the means already enu- 
merated, consists in preventing habitual postures that predispose to 
deformity, and in daily massage and manipulative correction of begin- 
ning distortions. Young infants and those whose bones are especially 
vulnerable should spend much of the time in the reclining posture. 
The Bradford frame, or similar appliance, is especially useful in the 
treatment of this class of cases. The treatment of the more advanced 
deformities, by support or by operation, is described elsewhere. 

"Late Rickets." 

Late rickets is, as the name implies, an affection presenting all the 
characteristics of the common infantile form. This, in rare instances, 
appears in later childhood or even in adolescence ; in some cases the 
affection appears to be a continuation or recrudescence of the infantile 
form ; in others no history of a preceding affection can be obtained. 1 

By many writers the term late rickets is improperly used to explain 
the deformities of adolescence, genu valgum, coxa vara and the like, 
although none of the distinctive signs of the affection may be present. 
Local rickets is less objectionable as applied to the same class of cases, 
although pathological specimens present little evidence of actual local 
disease. 

*Drewitt, Trans. Lond. Path. Soc, Vol. XXXIL, 1881. Clutton, St. Thomas' 
Hosp. Reports, Vol. XIV., 1884. 



INFANTILE SCORBUTUS. 367 



Foetal Rhachitis. 



Synonyms. — Chondrodystrophia, Achondroplasia. 

Cases that present the signs of what appears to be severe general 
rhachitis at birth, are not especially uncommon. The trunk is dis- 
proportionately long as compared to the stunted limbs ; the head is 
large, the chest presents a pigeon-like distortion and the epiphyses ap- 
pear to be generally enlarged. In some instances the back is curved 
into a rigid kyphosis or scoliosis, and restricted motion, or apparent 
fixation, of many of the joints may be present. 

Etiology and Pathology. — These cases were formerly supposed to 
be instances of intra-uterine rhachitis ; chondrodystrophia is not how- 
ever the result of a disturbance of nutrition, it is due apparently to a 
congenital defect in the bones themselves or rather of the original 
cartilage. Rhachitis is characterized by hypertrophy of the epiphyseal 
cartilages and by delayed ossification. In chondrodystrophia, on the 
contrary, there is atrophy of the epiphyseal cartilages and abnormal 
rapidity of ossification. On section of a bone the shaft is seen to be 
thickened and stunted, the epiphyses are enlarged also and these hyper- 
trophied and prematurely ossified segments may overhang the diminu- 
tive cartilage that intervenes. 

Chondrodystrophia, or an affection resembling it, is sometimes seen 
(Fig. 250) in a very mild form ; the appearance of the child suggests 
rhachitis, but the stunting of the growth is greater than is ever the 
result of rhachitis of corresponding severity. 

Cretinism. — Cretinism may cause a similar dwarfing of the stature, 
and cretinism may be combined with chondrodystrophia, but in most 
instances the symptoms of mental deficiency that accompany cretinism, 
are lacking in this affection. 

Treatment. — The treatment of so-called foetal rhachitis consists in 
regular massage and manipulation of the distorted parts and of the 
anchylosed joints. This treatment may extend over several years,, dur- 
ing which the limbs and back must be protected. Rest on the Brad- 
ford frame during the period of active treatment, is advisable. If 
congenital cretinism is suspected, the administration of thyroid extract 
would be indicated. 

Prognosis. — By persistent treatment the range of motion in the 
stiffened joints may be regained, but the prognosis is bad. The patients 
present in later years the abnormally long trunk and stunted extremi- 
ties that were present at birth. 

Infantile Scorbutus. 

Synonyms. — Scurvy, Scurvy Rickets. 

Scurvy in infancy, as at other periods of life, is a constitutional dis- 
ease, dependent upon impaired nutrition, caused apparently by the 
deprivation of proper food. The disease was originally described by 
Smith and Barlow as scurvy rickets, but it may, and often does, occur 
independently of the latter affection. 



368 AFFECTIONS LEADING TO GENERAL DISTORTIONS. . 

Pathology. — The pathological changes most often found in cases of 
the advanced type are hemorrhages beneath the mucous membranes 
and the periosteum. Separation of the epiphyses may occur. 

Symptoms. — The disease is most often observed in bottle-fed infants 
from six to eighteen months of age. In some instances the patients 
are evidently ill-nourished, but in others they may appear to be in 
good condition. The early symptoms resemble rheumatism. The 
child shows evidences of discomfort when certain joints are moved, and 
as the disease progresses it may scream whenever it is turned or lifted. 
The painful joints are sensitive to pressure and they may be somewhat 
enlarged, but local heat and redness, as well as fever, are, as a rule, 
absent. After dentition the gums may be swollen and spongy, and 
hemorrhages into the skin or beneath the mucous membranes may oc- 
cur. In extreme cases the swelling about a joint due to effusion of 
blood and accompanied, it may be, by separation of the epiphysis may 
be mistaken for the symptoms of infectious epiphysitis or even for 
sarcoma. 

Treatment. — The treatment consists primarily in the regulation of 
the diet, particularly in the substitution of fresh milk, properly modi- 
fied, for the patent food or sterilized milk that may have been em- 
ployed. This should be supplemented by orange juice, or that of other 
fresh fruit. The change of diet usually relieves the symptoms. Dur- 
ing the painful stage of the disease complete rest in the horizontal posi- 
tion on a pillow or frame, may be indicated ; later, massage of the 
limbs and back may be of service in improving the nutrition, and 
remedying slight deformity. 

Fragilitas Ossium. 

Synonym. — Idiopathic Osteopsathyrosis. 

There are many conditions that cause local or general fragility of 
the bones and thus an increased liability to fracture. For example, 
the weakness of old age, sometimes called senile rickets ; the atrophy 
caused by disuse incidental to chronic joint disease, or the weakness 
that may be caused by certain diseases of the nervous system. Weak- 
ness of the bones may be general in character, as when it is the re- 
sult of osteomalacia or rhachitis. 

Idiopathic fragility or osteopsathyrosis is of congenital origin. The 
bones appear to be weak simply because of a failure in the formation 
of periosteal bone. In such cases, there may be distortions at birth, 
apparently caused by intra-uterine fractures, and in after life, fracture 
may follow the slightest accident or sudden motion. Blanchard l has 
reported a case in which there were seventy distinct fractures between 
the ages of two months and twenty-seven years. A similar case was 
for many years under treatment in the Hospital for Ruptured and 
Crippled. For a part of the time the body and trunk were inclosed 
in a plaster of Paris casing, to prevent the fractures that followed even 

'Trans. Am. Orth. Ass'n, Vol. VI. 



OSTEOMALACIA. 



369 



ordinary movements. At the age of fourteen the strength of the bones 
had increased sufficiently to enable the patient to walk about with the 
support of braces, but he was, in stature, about the size of a child of 
seven years. 

Fractures in this class of cases are attended with but little pain. 
They unite slowly with but a small callus. It is practically impossible 
to prevent a certain amount of deformity. With advancing years the 
liability to fracture may diminish, but as a rule the patient is disabled. 

The treatment is pro- 
tective. Massage is of Fig. 251. 
service in improving 
nutrition. Medication 
is of little avail. 1 

Osteomalacia. 

Synonym. — Mollitis 
Ossium. 

Osteomalacia is a dis- 
ease of an inflammatory 
nature, characterized by 
an absorption of the 
earthy substances (de- 
calcification) of the 
bones and by deformity. 
The disease is one of 
adult life. It is far 
more common among 
females than males, and 
pregnancy, in about 
half of the cases that 
have been reported, 
seemed to be the excit- 
ing cause. The disease 
usually begins insidi- 
ously. The symptoms 

are pain on motion referred to the pelvis and to the thighs. This is 
supposed to be of rheumatic origin until the character of the affection 
is made evident by the weakness of the limbs and by the deformities. 
These deformities are of greater interest to the obstetrician than to the 
surgeon, for when the affection complicates pregnancy, the distortion 
of the pelvis may be so great as to prevent normal delivery. 

Osteomalacia in Childhood. — Three cases of osteomalacia in 
childhood have been reported by Siegert, 2 and one case has come under 
my observation. The patient, one of twelve living children of healthy 
parents, was nursed by his mother for the usual period, and until the 

^orak, Bui. et Mem. de la Soc. Obst. et Gyn. de Paris, 1890. Salvetti, Beitr. zur 
Path. Anat. und Allg. Path., Bd. XVI., 1894." 
2 Munch, med. Wochens., Nov. 1, 1898. 
24 




Osteomalacia. 



370 AFFECTIONS LEADING TO OENEEAL DISTORTIONS. 

age of four years he appeared to be perfectly healthy. At this time 
without known cause general weakness of the lower limbs became ap- 
parent, and at the same time deformities of the lower extremities de- 
veloped. At the age of six years he was unable to stand. At the 
present time the condition of the patient, now nine years of age, is 
shown in the preceding illustration. There is no evidence of rhachitis 
or of paralysis. The patient has never suffered from pain or discom- 
fort. The lower extremities are somewhat atrophied from disuse, the 
bones are abnormally flexible and are distorted to a moderate degree. 
The epiphyses are not enlarged. (Fig. 251.) 

Treatment. — As the etiology of the affection is unknown, treatment 
is symptomatic and palliative. 

Osteitis Deformans. 

This disease was first described by Paget 1 in 1877. It is a chronic 
inflammatory affection of the bones, characterized by hypertrophy and 
softening. "The bones enlarge, soften, and those bearing weight 
become unnaturally curved and misshapen." 

Section of an affected bone shows it to be markedly increased in 
size, and somewhat in length, by a combination of rarefying and form- 
ative osteitis. The inner layers become porous, and at the same time 
new bone is deposited beneath the periosteum. 

The disease appears to be confined to adult life, and is equally 
divided between the sexes. Although but a single bone may be affected, 
as a rule the lesion is symmetrical and more general in its area, the 
bones of the lower extremity, the skull and the spine being more often 
involved. Thus, the head progressively increases in size, and the legs 
become bowed. If the spine is affected it bends forward forming a 
long, more or less rigid, kyphosis. 

Aside from the deformities and the characteristic enlargement of the 
bones, the symptoms are not marked. At times complaint is made of 
pain usually supposed to be rheumatic until the characteristic changes 
in the bones appear. The disease is extremely chronic in its course, 
and as a rule the general health is not seriously affected. In several 
instances sarcoma of bone finally caused death many years after the 
onset of the disease. Its etiology is unknown, its treatment is palli- 
ative. 

Secondary Hypertrophic Osteo-Arthropathy. 2 

Osteo-arthropathy is an inflammatory disease of the bone character- 
ized by hypertrophy, clubbing of the fingers and effusion into certain 
of the joints. The hypertrophy is caused by a deposition of layers of 
bone beneath the periosteum of the metacarpal and metatarsal bones, 
the phalanges and the distal extremities of the adjoining bones of the 

J Med. Chir. Trans., Vol. 40 and Vol. 65, 1882. 

2 Marie, Kevue Medical, Paris, 1890, X., p. 1. Bamburger, Wiener klin. Woch., 
N. 11, 1889. Deutsche Chir., L. 28, 1899. 



ACROMEGALIA. 371 

arms and legs. Less often the area of the disease is more extensive, 
involving the femora, the humeri and the spine even. 

Osteo-arthropathy is usually a complication of preexisting chronic 
disease, most often of the lungs. The patient first notices clubbing of 
the terminal phalanges and hypertrophy of the finger nails, later an 
increasing enlargement of the wrists and ankles and of the hands and 
feet, accompanied by discomfort, sensitiveness to pressure and often by 
effusion into the neighboring joints, symptoms that would be classed 
as rheumatic were it not for the evident hypertrophy. 

The clubbing of the fingers is due, in part at least, to impairment 
of the circulation and the connection of the disease of the bones with 
that of the lungs has suggested the theory that it is caused by the ab- 
sorption of toxines and that its etiology is similar to the amyloid hy- 
pertrophy of the internal organs that sometimes follows chronic disease 
of bones and joints attended by suppuration. 

The treatment is symptomatic and as the affection is almost always 
secondary to a graver disease, but little is known of its outcome. It 
is certain, however, that the secondary osteo-arthropathic symptoms 
become less marked or may even disappear as the patient recovers from 
the original disease of the lungs or other organs. The affection is 
very uncommon in childhood, but one typical case having been recorded. 1 



Acromegalia. 

This affection is also characterized by progressive enlargement of the 
hands and feet, but it differs from osteo-arthropathy in that all the 
tissues are involved in the hypertrophy. The hypertrophy of the bone 
is limited to the epiphyseal extremities and is slight compared with 
that of the soft parts. The face is often involved, the tissues of the 
nose, lips and ears being enlarged and thickened, together with the 
underlying bones, so that the expression is very markedly changed. 

Acromegalia is common among those of gigantic stature. The'local 
hypertrophy and the giganticism both being due, it is supposed, to dis- 
ease of the pituitary gland. 

Diagnosis. — The three affections that have been described, osteitis 
deformans, osteo-arthropathy and acromegalia, are rare diseases and 
they are of little practical interest to the surgeon other than from the 
standpoint of diagnosis. This might be somewhat difficult if the pa- 
thological process were confined to a single bone or limb, as is some- 
times the case in osteitis deformans. 

The essential characteristics of the three diseases may be summarized 
as follows : In osteitis deformans the entire bone is increased in size 
and length, and because of the coincident weakening of its structure, it 
becomes distorted ; the skull is often involved but the hands and feet 
are not often affected. It is a disease of middle or later life and there 
are, as a rule, no symptoms other than those due to the local changes 
in the bones. 

1 Whitman, Pediatrics, February 15, 1899. 



372 AFFECTIONS LEADING TO GENERAL DISTORTIONS. 

In osteoarthropathy the process is an hypertrophy, but of a slight 
degree, caused by deposition of periosteal bone especially about the 
distal extremities of the shafts of the bones adjoining the hands and 
feet. It is not often accompanied by the weakness or the deformity 
that is characteristic of the preceding affection ; the skull is not usually 
involved, but the long bones of the hands and feet are thickened so 
that these members are markedly increased in size. There is often 
coincident discomfort and swelling of the neighboring joints. As a 
rule the local affection of the bones is secondary to chronic disease 
of the lungs. 

In acromegalia the marked changes are hypertrophic enlargements 
of the hands and feet in which all the tissues are involved ; the hyper- 
trophy of the bones is most marked about the epiphyses, the diaphyses 
remaining unaffected ; thus it differs from the preceding disease, in 
which similar enlargement of the extremities occurs. The head is 
often involved, but the hypertrophy is of all the structures of the face, 
not of the skull as in osteitis deformans. 

The disease appears to be confined to early adult life and it is often 
preceded or accompanied by symptoms of a general nature, headache, 
mental impairment and the like. 

The changes in the bones characterizing the affections may be easily 
demonstrated by means of the Roentgen pictures. 



CHAPTER XIV. 

CONGENITAL DISLOCATION OF THE HIP AND 
COXA VARA. 

Congenital Dislocation at the Hip Joint. 

Of all the congenital dislocations or, perhaps, more properly mis- 
placements, that of the hip joint is by far the most common and the 
most important. 

Statistics. — Congenital dislocation of the hip is much more common 
in females than in males. In 671 cases collected from different sources 



Fig. 252. 




Congenital dislocation of the hip showing the elongated capsule and the right angled relation of the 
neck to the shaft of the femur. (William Adams. ) 

by Lorenz, 589 (87.8 per cent.) were in females and 82 (12.2 per cent.) 
in males. Of 1,039 cases seen at the Polyclinic in Milan, 867 (83.4 
per cent.) were in females, 172 (16.6 per cent.) in males. 1 In 500 
cases from the records of the Hospital for Ruptured and Crippled, in- 

1 Bernacchi, Zeits. Orth. Chir., Vol. II., p. 275. 



374 CONGENITAL DISLOCATION OF THE HIP. 

vestigated for me by Dr. C. P. Flint, 413 (82.6 per cent.) were in 
females and 87 (17.4 per cent.) in males. 

The dislocation is more often unilateral than bilateral. In Lorenz' 
series of 671 cases, 421 (64.4 per cent.) were single ; 225 of the right, 
196 of the left side. In 245 cases (36.6 per cent.) the displacement 
was bilateral. 

Statistics of 500 Cases of Congenital Dislocation of Hip, Recorded 
at the Hospital for Ruptured and Crippled. 

Males 87 17.40 per cent. 

Females 413 82.60 " 

Total... 500 100.00 " 

Right hip 135 27.66 per cent. 

Left hip ....218 44.47 " 

Both 136 27.87 " 

489 100.00 " 

Not specified 11 

500 

Males. 

Right hip 25 30.48 per cent. 

Left hip 32 39.04 " 

Both _2_5 30.48 

~82 100.00 " 

Not specified 5 

~87 

Females. 

Right hip 110 27.04 per cent. 

Left hip 186 55.69 " 

Both Ill 27.27 

407 100.00 " 

Not specified 6 

413 

The dislocation at the time when the patients are brought for treat- 
ment is almost always posterior, upon the dorsum of the ilium ; in 
other instances it is anterior, so that the head of the bone may be felt 
beneath the anterior superior spine. It is possible however that the 
primary displacement may be in certain instances directly upward. 

Pathology. — The pathological anatomy of the dislocation was first 
clearly demonstrated by Dupuytren in 1826, and since 1890, when the 
open operation was first performed, the exact relation and the appear- 
ances of the different components of the joint have been described in 
detail by Hoffa, Lorenz and other operators. 

The condition of the joint varies with the age of the patient and the 
strain and friction to which the displaced parts have been subjected. 
In early infancy it may be assumed that the head of the bone lies in 
close proximity to what is, in some instances, a practically normal 
acetabulum ; in others to one that is somewhat rudimentary, often 



PATHOLOGY. 



375 



shallow and small, sometimes of an oval but usually of a somewhat 
triangular shape. The acetabulum is covered with normal hyaline 
cartilage, the ligamentum teres is present and the capsule is of nearly 
normal structure. At a later time when the joint is exposed at oper- 
ation at the age of five or more years, the rudimentary acetabulum may 
be partly filled with cartilage, fat and fibrous tissue, so that it may be 
almost on a level with the surrounding bone. As a rule, however, a 
well-marked ridge indicating its posterior and upper margin can be 
made out and in many instances it appears to be of fair size and depth. 
The capsule is elongated to accommodate the upward dislocation of the 
femur. It is hyper trophied, especially where it covers the upper part 
of the head of the bone, and it is often drawn into a shape like an 
hour glass ; the upper part con- 
tains the head of the bone, the Fig. 253. 
anterior wall is drawn tightly 
across the acetabulum, forming 
at its upper border a narrow slit- 
like communication, through 
which the ligamentum teres 
passes, if it be present. (Fig. 
252.) The interior of the cap- 
sule is in part lined with syn- 
ovial membrane, and it often 
contains more synovial fluid than 
is found in the normal joint. 

The ligamentum teres, al- 
though probably present at birth 
in a large proportion of the cases, 
becomes attenuated and ribbon- 
like with the increasing elonga- 
tion of the capsule, and after the 
age of five years or at the time 
when the open operation is per- 
formed, it is usually absent. 
According to Lorenz in 52 cases 
between two and a-half and five years it was present in 17 ; in 48 
cases beyond the age of five years it was present in but 4. In rare 
instances it may be hypertrophied. In my own experience the liga- 
ment is present in a very much larger proportion of the cases, although 
it is often so rudimentary that it might easily be overlooked. 

A shallow secondary acetabulum, formed in part by the direct 
pressure of the head of the bone through the adherent capsule, and in 
part the result of irritation of the periosteum, is usually found upon the 
ilium (Fig. 253), but it is not often of sufficient depth to assure a secure 
support for the head of the femur ; thus its upper margin gradually 
recedes or two distinct depressions may be formed one above the other. 
The upper extremity of the femur is usually somewhat atrophied. 
The neck is often shorter than normal, and its angle may be lessened, 




Congenital dislocation of the hip, showing the orig- 
inal and the acquired acetabula. (Lorenz.) 



376 



CONGENITAL DISLOCATION OF THE HIP. 



and in many instances its forward inclination is increased. The head 
of the bone may be nearly normal although usually it is somewhat 
flattened on its inner and under surface, or it may be somewhat conical 
in shape, or again compressed from side to side to an almond shape or 
otherwise distorted. The abnormalities, in part congenital, become 
more marked with age, and in adult specimens the head and neck of the 
femur may be so atrophied and worn away that it has little semblance 
of normal contour. (Fig. 254.) 

There are also secondary changes in the bones of the pelvis. In 
unilateral dislocation the pelvis is usually somewhat atrophied on the 

Fig. 254. 





Congenital dislocation of the hip showing the depressions in the ilium and the final effect of pressure 
and friction upon the femur. (Adams.) 



affected side, and a lateral inclination of the spine may be present. 
The final changes in the pelvis caused by the bilateral dislocation, are 
more important ; its inclination is increased, the lumbar lordosis is ex- 
aggerated, the sacrum is forced forward and downward so that the an- 
teroposterior diameter is lessened ; the tuberosities of the ischia are 
everted and the transverse diameter of the pelvic outlet is increased. 

The long muscles of the thigh are shortened, while those attached 
about the trochanter are changed in direction and are usually length- 
ened. There is also a slight general muscular atrophy that is particu- 
larly marked in the gluteal group. 



ETIOLOGY. 377 

The changes that have been described are in great degree secondary 
to the displacement. They are in part congenital, in part accommoda- 
tive and in part due to the influences of attrition and injury, to which 
the abnormal mobility predisposes ; thus, as a rule, they become 
more marked with increasing age, and in some of the adult specimens 
but little resemblance to the normal parts remains. 

As a rule, congenital dislocation of the hip is not accompanied 
by defective development or deformity elsewhere : although cases 



Fig. 255. 



Fig. 256. 





Unilateral dislocation showing the inclination 
of the body toward the shorter leg. 



The same patient before operation, showing 
the abnormal lordosis and rotation of the pel- 
vis. (See Figs. 270, 271.) 



are sometimes seen in which a general laxity of ligaments is present 
or in which the dislocation may be one of a series of deformities and 
malformations. 

Etiology. — Nothing positive is known of the etiology of the dislo- 
cation. In a small proportion of the unilateral cases it may be due to 
violence at birth, but the fact that nearly 85 per cent, of the patients 
are females makes it evident that the primary cause can be neither in- 
jury nor disease. 



378 



CONGENITAL DISLOCATION OF THE HIP. 



Fig. 257. 



Hereditary influence can be established in a few instances. The 
writer has examined three female children in a family of nine, in each 
of whom there was dislocation of the left hip, the order being the third, 
eighth and ninth child. Also twins in another family, one having 
single and the other double dislocation. And in two instances, con- 
genital displacement was present in the mothers of patients. 

Of the various theories that have been advanced to account for the 

condition, the most reasonable 
seems to be defective develop- 
ment. This defective develop- 
ment may affect the entire aceta- 
bulum or it may involve only its 
posterior margin, or the cause of 
the displacement may be an ab- 
normal laxity of the capsule that 
predisposes to displacement when 
the thighs are flexed and ad- 
ducted. 

Heusner, 1 from an examination 
of 26 foetuses concluded that the 
greater liability of females to the 
dislocation is explained by the 
disproportionate laxity of the cap- 
sule as compared with males. 

It is probable that the disloca- 
tion, in some cases at least, is at 
birth a subluxation only, that be- 
comes complete through muscu- 
lar action and the use of the limb 
in standing and walking. 

Symptoms. — The displace- 
ment does not as a rule attract 
attention until the child begins to 
walk ; although in some cases the 
mother may have noticed a pe- 
culiar breadth of pelvis, or a 
" lump " on the buttock, or a 
" snapping " about the hip joint, 
or a peculiar attitude of the limb 
before this time. 
Unilateral Dislocation. — If the displacement is of one side, a 
limp is immediately apparent, which becomes more noticeable as the 
child grows older. The limp is peculiar and its character is explained 
by its cause ; for the leg is not only shorter than its fellow, but owing 
to the elasticity of the capsule, it becomes still shorter when the weight 
falls upon it, so that in walking there is a peculiar lunge of the body 
toward the short leg, that has been likened to the motion in walking 
>Zeits. fiirOrth. Chir., Bd. V., H. 2, 3. 




Congenital dislocation of both hips, illustrat- 
ing the separation of the thighs, the abnormal 
breadth of the pelvic region, and the prominent 
trochanters. 



SYMPTOMS. 



379 



down stairs. The head of the bone is displaced upward and back- 
ward, and in compensation the pelvis is tilted toward the short leg and 
its inclination is increased ; it is thus twisted downward and forward 
so that the anterior superior spine lies at a lower level, and in advance 
of that of the opposite side. (Figs. 255, 256.) 

At an early age the shortening of the leg, due to the elevation of 
the trochanter, is from one-half to three-quarters of an inch. In ado- 
lescence, the elevation 

is from one and one- Fig. 258. 

half to two inches, and 
in adult life it may be 
considerably more. 

The effect of the 
displacement is also 
shown by a flattening 
of the buttock, and 
usually the elevated 
and prominent trochan- 
ter may be seen as an 
abnormal lateral pro- 
jection, on a level with 
the anterior superior 
spine which is, as has 
been stated, somewhat 
tilted downward. 

In childhood, mo- 
tion in the false joint is 
more free than normal, 
and the abnormal mo- 
bility can be demon- 
strated by alternate 
traction and upward 
pressure on the limb, 
but as the femur be- 
comes larger and the 
upward displacement 
increases, the mobility 
is restricted ; the range 
of abduction is much 
diminished, and not in- 
frequently the limb be- 
comes permanently ad- 
ducted and flexed, thus adding the apparent shortening of adduction 
to that caused by the dislocation. (Fig. 259.) 

Bilateral Dislocation. — When the location is bilateral the 
shortening is, as a rule, equal or nearly so, and as both femora are 
displaced backward the pelvis is tilted forward ; thus in compensation 
"the hollow" of the back is increased, the abdomen protrudes, the 





'.I 


B - .. : 8 JgH 

1 | 8 

m 

r H 1 

• • 



Bilateral congenital dislocation of the hip, showing the exag- 
gerated lordosis. 



380 CONGENITAL DISLOCATION OF THE HIP. 

buttocks are flattened, the pelvis appears to be abnormally wide and 
the thighs are separated by a considerable interval. (Figs. 257, 258.) 
The limp characteristic of the single displacement is replaced by an 
exaggerated waddle, a " sailor gait." 

General Symptoms. — In early childhood there are no especial 
symptoms other than the limp or the waddle but as the child becomes 
more active it usually complains of discomfort after exertion. It is 
easily fatigued and at times it may suffer actual pain. These symp- 
toms are of course more marked in the double than in the single dis- 
placement, because in the latter case the normal leg is capable of bear- 
ing more than its share of the strain. The symptoms often increase 
during adolescence but they may become less troublesome in adult life, 
when the head of the bone may have found a permanent resting place 
on the pelvis ; a security assured, however, by a corresponding limita- 
tion of the range of motion. But the shortening and the secondary 
effects of the displacement of course remain, so that the individual 

Fig. 259. 





Congenital dislocation ia an adolescent, illustrating the flexion-contraction in a well-marked case. 

is, as compared with the normal standard, more or less disabled and 
deformed. 

The great majority of the patients are females and because of the 
less laborious occupations and the distinctive dress, the disability and 
its effects are less serious than if the displacement were more equally 
divided between the sexes. 

Anterior Dislocation. — The symptoms of the anterior disloca- 
tion in which the head of the bone lies beneath the anterior superior 
spine, are much less marked because the relation of the pelvis to the 
femur is nearly normal, so that secondary deformity is slight. The 
shortening is less and the resistance of the tissues attached to the an- 
terior superior spine is sufficient to assure a more secure support than 
in the ordinary form. 

Diagnosis. — The diagnosis offers no difficulty. The history of the 
limp or waddle noticed when the child began to walk and yet unac- 
companied by pain or preceded by injury or disease, is in itself snffi- 



DIAGNOSIS. 



381 



ciently distinctive. If the displacement is of one side, measurement 
demonstrates the shortening as compared Avith the other limb, a short- 
ening that is explained by the prominence, and the elevation of the 
trochanter above Nekton's line. Traction and upward pressure on the 
leg will demonstrate the abnormal mobility of the displaced head ; and 
finally if the thigh be flexed and adducted to its extreme limit, the 
neck and head of the femur can be easily distinguished moving under 
the gluteal muscles when the leg is rotated. Thus it may be differen- 
tiated from depression of the neck of the femur (coxa vara), in which, 
although the trochanter is elevated, the neck and head of the bone can- 

Fig. 260. 




Bilateral congenital dislocation of the hip. 

not be felt, and in which the abnormal mobility, characteristic of the 
dislocation, is absent. Again, coxa vara is almost never a congenital 
affection, therefore the history itself would practically exclude it. 

Upward displacement of the femur not infrequently follows infec- 
tious epiphysitis of infancy or early childhood. In such cases a part 
of the upper extremity of the bone is usually destroyed so that the head 
cannot be distinguished on palpation. Although the other physical signs 
are similar to those of the congenital displacement, the scars about the 
joint show the evidence of former disease, and the history is almost 
always available for diagnosis, so that as a rule, such disabilities, as 



382 



CONGENITAL DISLOCATION OF THE HIP, 



Fm. 261. 



well as traumatic dislocations or other results of injury or disease, are 

readily excluded. (Fig. 217.) 

The double congenital dislocation presents the same local signs as 

the single form ; it is even more easily recognized by the peculiar 

appearance and distinctive gait of the patient. 

The waddling gait may be simulated by that of extreme bow legs, 

but the hip joints are, in this deformity, normal in appearance and 

function. The waddle of lumbar 
Pott's disease is also somewhat simi- 
lar, but this is an acquired painful dis- 
ease of the spine, in which the hip joints 
are normal in appearance and usually 
so in function. 

PSEUDOHYPERTROPHIC PARALYSIS 

may be mentioned as causing a some- 
what similar gait and attitude, but here 
the resemblance ceases. 

As has been stated, the diagnosis of 
congenital dislocation can be easily made 
by physical examination ; the only real 
difficulty is experienced in early infancy 
when the dislocation may be incomplete, 
but opportunity for such early diagnosis 
is rarely offered. 

In doubtful cases a Roentgen picture 
will demonstrate the character of the 
disability. (Fig. 260.) 

Treatment. — Dupuytren in 1829, 
after a careful study of the anatomy of 
the deformity, made the statement that 
it was not only incurable but that pal- 
liation of its effects even was hardly 
attainable; and for sixty years the state- 
ment remained practically undisputed. 
The term dislocation naturally sug- 
gests that cure can only be attained by 
replacement of the displaced bone in its 
proper place, and in 1890 Hoffa of 
Wurzburg first performed this operation 
with success, by opening the joint from 
behind and enlarging the rudimentary acetabulum to a size sufficient 
to contain the head of the bone. Since this time the details of the 
operation have been modified, particularly by Lorenz of Vienna, 1 who 
has written the most complete works on the subject. 

The radical cure of the dislocation can be accomplished by several 
procedures : 




Bilateral dislocation in adolescence. 
This patient was practically disabled 
by pain and weakness. 



1 Pathologie und Therapie der Angebornen Hiift Verrenkung. Wien, 1895. 
ilung der Angebornen Hiiftgelenk Verrenkung. Leipzig u. Wein, 1900. 



Ueber 



heilung 



TREATMENT. 383 

1. The open operation with direct enlargement of the rudimentary 
acetabulum. 

2. Forcible replacement and gradual reformation of the joint by 
functional use. 

3. The intermediate operation. 

The Open Operation. — As a preliminary treatment the head of the 
bone must be drawn down to a point corresponding to its normal posi- 
tion, so that the trochanter is on the level of Nelaton's line or even 
below it. In the older subjects, traction in bed by means of adhesive 
plasters and the weight and pulley, as described in the treatment of 
hip disease may be employed for this purpose with advantage. (See 
page 269.) From 10 to 40 pounds of weight may be used according 
to the age of the patient and the resistance of the tissues. In using 
this strong traction, excoriations must be guarded against by constant 
supervision and readjustment of the perineal bands, and by lessening 
the weight from time to time when it causes discomfort. In younger 
subjects the tissues may be sufficiently stretched by manual force at 
the time of operation. 

A folded sheet is passed beneath the perineum, the two ends of 
which are held by an assistant at the head of the table, and by means 
of intermittent and continuous manual traction the resistance of the 
contracted parts is overcome. The traction machine of Lorenz may be 
used for the same purpose, but, as a rule, the preliminary extension in 
bed is to be preferred to the use of extreme force at the time of opera- 
tion. When the tissues are sufficiently relaxed to allow the trochanter 
to be drawn down to its normal position, the joint is exposed by a lat- 
eral incision about three inches in length, extending downward from a 
point about three-quarters of an inch to the outer side of the anterior 
superior spine of the ilium, the fascia is divided and the line of junction 
between the tensor vaginae femoris and the gluteus medius muscles is 
found. These muscles are then separated and are drawn to either side 
by retractors, thus exposing the capsule of the joint. The ilio-psoas 
muscle, which often covers its anterior surface, is separated from it and 
the capsule is opened by an incision parallel to the neck of the bone. 
The finger is then passed through the opening, down upon the rudi- 
mentary acetabulum. A strong cervix dilator is then inserted and the 
contracted capsule is thoroughly stretched. If the ligamentum teres is 
present, it is removed ; a large sharp spoon is then introduced by the 
side of the finger and the acetabulum is enlarged to its normal size by 
removing from its interior the fibrous tissue, fat and thickened carti- 
lage. If the acetabulum appears to be of sufficient size, as is not in- 
frequent in young subjects, this procedure may be omitted, but in such 
an event the danger of redisplacement is greater and the limb must be 
fixed in an attitude of flexion and abduction, as described in the func- 
tional weighting method. (See the intermediate operation.) 

If the head of the bone is extremely irregular it may be remodeled, 
but this is rarely necessary. If there is marked anterior rotation. of 
the neck upon the shaft, the head should be replaced in the acetabu- 



384 



CONGENITAL DISLOCATION OF THE HIP. 



lum, the leg being rotated inward to a sufficient degree to prevent re- 
displacement. Later, by means of a simple linear osteotomy below the 
trochanter minor, the shaft may be rotated outward and the normal 
relation of the parts restored. In six instances I have found this 
secondary operation to be necessary. (See osteotomy.) 

After the head has been replaced the wound may be closed, but if 
the acetabulum has been excavated a small opening should be left for 
drainage as the serous discharge is usually considerable in amount. 1 A 
plaster of Paris spica bandage is then applied, the leg being fully ex- 
tended, somewhat abducted, and rotated as a rule slightly inward, so 
that the head of the bone may be completely contained within the new 

acetabulum. The first band- 
Fig. 262. age usually remains in position 

for about eight weeks; it is 
then replaced by one which 
reaches to the knee only, and 
the patient is encouraged to 
bear the weight on the limb. 
At the end of another month 
or longer, when it may be 
supposed that repair is com- 
plete and when the joint is no 
longer sensitive to direct man- 
ipulation, the spica is removed. 
If possible regular massage 
and methodical exercises with 
the aim of stimulating and 
strengthening the disused and 
misplaced muscles, should be 
begun and continued for a 
year, or longer if necessary. 

After the open operation 
the range of motion is at first 
much limited and forced man- 
ipulation causes pain. There 
is also in many instances a 
tendency toward flexion and 
adduction. This is due in part to the original traumatism of the opera- 
tion, in part to the weakness of the abductor and extensor muscles, 
and in some instances to the depression of the neck of the femur that 
may be present. 

This tendency toward deformity must be resisted by massage and 
manipulation and by the use of apparatus if necessary. A useful form 
of appliance for the purpose of holding the leg in the proper attitude, 
is a simple jointed leg brace attached to the shoe and to a pelvic band. 
(Fig. 263.) If the contraction is resistant forcible manipulation under 
anaesthesia may be required. 

1 Hoffa does not close the wound, but packs it lightly with gauze. 




Scoops used in the treatment of congenital dislocation, 
also the subcutaneous osteotome. 



TREATMENT. 



385 



After the operation the legs may be equal in length, but there is as 
a rule a shortening of about a half inch caused by the excavation of 
the acetabulum and by the depression of the neck of the bone. A 
limp persists for a year at least and usually longer, the successful 
functional result being dependent upon the age of the patient and upon 
the care that has been exercised in the after-treatment. As a rule 
traces of the former disability will remain in most instances throughout 



Fig. 263. 



Fig. 264. 



Fig. 265, 





^ 







«^i 



A successful result after 
the open operation. Shows 
a useful form of brace to be 
used in the after-treatment. 



Eight months after operation by 
the open method. 



Bilateral dislocation 
six months after replace- 
ment by the open method. 
Illustrating the change in 
the contour of the trunk. 



life because of the abnormalities of the head and neck of the bone or 
elsewhere, but in a large proportion of suitable cases, practical cure 
may be obtained, and in all the progress of the deformity may be 
checked and the symptoms relieved because the head of the bone has 
been provided with a secure resting place in its normal position. Ee- 
lapse is unusual if the operation has been properly conducted, unless 
the neck of the bone is displaced forward in its relation to the shaft so 

25 



386 CONGENITAL DISLOCATION OF THE HIP. 

that it may be impossible to retain the head in the acetabulum unless 
the foot is rotated inward. 

The danger of the operation is slight, and the deaths with but few 
exceptions have been due to infection. Lorenz and Hoffa lost several 
of their earlier patients from this cause, but with improved technique 
the danger is slight. 1 The bad results of the operation may, as a rule, 
be accounted for by its improper performance, particularly the failure 
to replace the femur securely, or by failure to insure asepsis, or by in- 
efficient supervision and after-treatment. 

It is perhaps unnecessary to state that operations of this character 
should not be performed unless asepsis can be assured, unless the oper- 
ator is familiar with the anatomy of the parts and unless the essential 
after-treatment can be provided. 

The prognosis in bilateral displacement is much less hopeful than in 
the single displacement for the evident reason that the original dis- 
ability as well as the chances of operative mishap are twice as great. 

Reduction of the Dislocation without Open Operation. The " Func- 
tional Weighting Method of Lorenz." — The Lorenz treatment is based 
upon the theory that if parts about the joint may be sufficiently 
stretched to allow the head of the bone to be brought into direct con- 
tact with the rudimentary acetabulum, and if it can be held in this 
position, the weight of the body, in walking, constantly forcing the 
bone against the substance that partly fills it, will gradually enlarge it 
to its normal capacity ; thus it is called the " functional weighting " 
method, and this is its essential and vital distinction from the forcible 
correction of Paci, with which it is often confounded. 

The steps of the operation are : 1. Elongation of the limb. — The 
trochanter must be brought down to the level of Nekton's line or lower. 
This may be accomplished by preliminary traction in bed with heavy 
weights, or by manual force at the time of operation, the latter means 
being efficient in young subjects. The child having been anaesthetized, 
a folded sheet is passed between the legs and the two ends are held 
above the shoulder of the side to be operated upon, or the assistant 
may clasp his hands about the perineum and thus fix the pelvis. One 
then seizes the thigh and begins a series of alternate stretchings and 
relaxations, using gradually increasing force for from ten to twenty 
minutes, or until the resistance of the tissues is entirely overcome. The 
leg is then as long or longer than its fellow and lies limp in an attitude 
of abduction. 

For this preliminary extension Lorenz uses a powerful machine at- 
tached to the leg by means of a band about the ankle, but I am inclined 
to think that the manual method is to be preferred if one does not ob- 
ject to the labor that it involves. 

2. Reposition. — One now attempts to force the head of the femur 

1 Hoffa has performed the operation 248 times with 10 deaths — 8 due to the opera- 
tion, the last 132 operations without a death. Lorenz in 260 operations lost 4 patients 
from septicaemia. — Report of the Thirteenth International Congress, Paris, August, 
1900. 



THE LORES Z OPEBATIOX. 



387 



over the ridge that represents the posterior margin of the acetabulum 
and through the opening in the contracted capsule. 

The thigh is flexed to about ninety degrees in order to relax the cap- 
sule ; it is then gradually and forcibly abducted under traction to 
the limit of the range, or slightly beyond even, so that the head 
and neck of the bone may lie in the same plane with the side of the 
pelvis ; the thigh is then rotated slightly inward so that the head of 
the bone may point toward the opening in the capsule, and while trac- 
tion upon the thigh is continued with one hand the other exerts pres- 
sure upon the trochanter and head of the displaced bone, Avhich is then 
lifted and drawn over the obstacle formed by the rim of the acetabulum. 
If this is successfully accomplished one hears and feels a distinct sound 
and shock, and the leg remains fixed in an attitude of flexion and ab- 
duction. From this semi- 
replacement the bone is at r Fig. 266. 
once displaced when the leg 
is adducted or extended. 

3. Acetabulum For- 
mation. — One now at- 
tempts to enlarge the open- 
ing of the acetabular part 
of the capsule. While the 
head of the bone is forced 
against or through the open- 
ing, the thigh is forcibly 
rotated outward again and 
again, and extended to its 
full limit, in order that the 
anterior wall of the capsule, 
which is drawn tightly 
across the depression, may 
be distended and the capac- 
ity of the new articulation 
increased. Finally, the pa- 
tient is turned upon the side 
and direct pressure is ex- 
erted on the trochanter 
while the limb is alternately 
flexed and extended. 

When the manipulation is 
completed, the leg is fixed 
in the attitude of extreme 
abduction, moderate flexion and inward rotation, by a firm plaster spica 
bandage extending to the knee, or preferably, slightly below it, the 
leg being flexed somewhat on the thigh. This longer bandage insures 
better fixation, and prevents the tendency to outward rotation, although 
it interferes somewhat with locomotion. 

At the time of operation one is able to make a fair prediction as to 




Unilateral dislocation, showing the attitude in the early 
stage of the Lorenz treatment. 



388 



CONGENITAL DISLOCATION OF THE HIP. 



its outcome from the character of the reposition and its stability. In 
some instances the head of the bone seems to be actually replaced in a 
sufficient cavity, in others, it appears to slip from side to side with but 
little indication of fixation. 

In properly selected cases the operation is free from danger, 1 and the 



Fig. 267. 




Unsuccessful treatment by forcible correction. (Lorenz operation.) The posterior has been changed 
to an anterior displacement. Rear view. 

1 Several deaths from the anaesthetic employed have been reported, three of these 
by Lorenz, and a number of accidents have been caused by violence in the attempt to 
reduce the displacement in adolescents. 



THE LORENZ OPERATION. 389 

pain and discomfort are much less than one would expect after the 
force that has been employed. Occasionally there is some discoloration 
about the adductor region, but this is practically the only noticeable 
evidence of the manipulation. 

As soon as possible the child is encouraged to stand and to walk, 
the awkwardness caused by the extreme abduction being somewhat 
lessened by a cork sole, an inch or more in thickness, on the other 
shoe. 

The first bandage should remain in place, if possible, for six weeks 
or longer. When it is removed, one examines the relation of the 
parts ; if the reposition has been unsuccessful the head of the bone 
may be felt beneath the anterior superior spine ; the posterior has 
been transformed simply into an anterior displacement. In such 
cases the operation may be repeated, but in my own experience the 
secondary operation has never been successful. If the head of the bone 
appears to be in its proper position, the bandage is again applied. At 
the end of another month or more, and with each successive change 
thereafter, the extreme attitude of abduction may be somewhat lessened, 
until, at the end of eight or ten months, the normal attitude of the limb 
is restored. The plaster bandage is then removed, but it is well to re- 
place it by a simple jointed brace attached to the shoe and to a pelvic 
band, by this means the foot may be rotated slightly inward and mod- 
erate pressure may be exerted on the trochanter. (Fig. 263.) 

During the course of treatment a failure in reposition usually be- 
comes evident, and in any event success is not assured until after all 
support has been removed. Roentgen pictures are, of course, of service 
in showing the true relation of the parts, if they are available. 

As this operation was first performed in 1895, sufficient time has 
not elapsed to report definitely upon final results. But in selected 
cases I am inclined to believe that about 25 per cent, of the patients 
may be cured by this means alone. The treatment of bilateral displace- 
ment by this method is less satisfactory. As a rule it is advisable to 
operate upon but one hip at a time. 

It should be stated that a method of forcible correction, preceding that 
of Lorenz, was introduced by Paci of Pisa in 1887. l Another, and 
somewhat similar, system is practiced by Schede. 2 As these methods 
are less definite and satisfactory than that of Lorenz, a detailed account 
of them is unnecessary. 

If the simple operation is unsuccessful, it must be supplemented by 
the open method. This will be necessary in the larger proportion of 
cases, particularly in older subjects, but the second operation will be 
much simpler and more easily performed because the preliminary treat- 
ment will have improved the relation of the parts. 

The great advantage of this treatment is, that it can be applied as 
soon as the diagnosis is made, for being free from danger and not ne- 
cessitating a cutting operation or confinement to a hospital, the consent 

1 Archiv di Ortop., 1892, p. 420. 

2 Archiv f. Klin. Chir., Bd. 43, 1892. 



390 



CONGENITAL DISLOCATION OF THE HIP. 



of parents is readily obtained ; this is certainly not true of the older 
method. There is also another advantage, in that the muscles become 
accommodated to the changed relations of the parts while the leg is 
fixed by the plaster bandage, so that the long-continued supervision 
and gymnastic training, that are essential after the open operation, may 
be dispensed with. Even if the 

operation has merely resulted in Fig. 269. 

changing a posterior into an anterior 
displacement, it may be classed as 

Fig. 268. 




I 



1 



2f 





Unilateral dislocation. Two 
years after operation by the Lorenz 
method. A complete cure. 



Unilateral dislocation. Eighteen, months after 
operation by the Lorenz method. A complete cure. 



a half cure, since the deformity of the spine is checked and the short- 
ening of the leg is much reduced. 



The Intermediate Operation. 

The uncertainty of the forcible operation on the one hand and the 
limitation of motion and distortion that may follow the enlargement of 
the acetabulum on the other, suggest the desirability of an intermediate 



REVIEW OF THE TREATMENT. 



391 



operation which may combine in some degree the advantages of each. 
Such is the operation of simple replacement by means of open incision. 
The operation is identical with that described except that the acetab- 
ulum is not enlarged, and that the further details of the non-bloody 
operation are followed. The limb is fixed in a position of abduction 
and inward rotation, although not in as extreme 
Fig. 270. degree as when the open incision 

has not been employed. Fig. 271. 




Secondary Osteotomy. 



** 



> 



/ 



If on examination during the 

open operation the neck of the 

femur is found to be anteverted 

to a marked degree, its relation 

to the shaft must be restored, 

otherwise the anterior displace- 
ment is inevitable when the limb 

is replaced in the proper attitude. 

To accomplish this the shaft of 

the femur may be divided by the 

subcutaneous osteotome just below 

the trochanter minor, a long 

slender drill is then inserted 

through the trochanter into the 

neck of the femur. This controls 

the upper fragment and indicates 

its position. The shaft is then 

rotated outward to the proper de- 
gree and a plaster spica bandage 

is applied, through which the drill 

projects. In a few days it may be 

removed. The details of the 

after-treatment do not differ from 

those of the ordinary cases. 
Review of the Treatment of 

Congenital Dislocation of the 
Hip. — The prospect of success iu treatment stands in direct relation to 
the age of the patient, since the extent of the pathological changes 
that make cure difficult or impossible, depends in some degree, as in 
acquired dislocations, upon the duration of the disability. Conse- 
quently treatment should be applied as soon as the displacement is 
discovered, and, as has been stated, there is little excuse for not mak- 
ing the correct diagnosis as soon as the child begins to w T alk. The 
treatment of selection, before the age of six years, is the functional 
weighting method of Lorenz. By this means a certain proportion of 
the cases may be cured, and in all instances the posterior may be 
changed into an anterior displacement, which makes the after-treat- 



TJnilateral disloca- 
tion. After operation 
by the Lorenz method. 
A complete cure. Com- 
pare with Fig. 255. 



Unilateral disloca- 
tion. Two years after 
operation. " Compare 
with Fig. 256. 



392 COXA VARA. 

raent much easier. If this treatment is ineffective, it should be fol- 
lowed by the open method. In the younger patients, simple incision 
and forcible stretching of the capsule may be sufficient, if the acetab- 
ulum is well formed ; if not, it will be necessary to enlarge it to the 
normal size. The same system may be followed in older children, but 
the simple correction is much less likely to be successful although 
cures have been reported at ages far beyond this limit. As a rule then, 
in this older class the open operation may be performed primarily, the 
operation being preceded if possible by traction in bed, so that all con- 
tractions may be completely overcome. In patients beyond the age of 
ten years the prognosis is very doubtful, although the treatment may 
be attempted in suitable cases. 

All other methods of treatment, by long-continued traction in bed, 
by braces for support or pressure — by tenotomy and scarification of the 
part — by " sclerogenous injection " and the like, have been practically 
abandoned. 

For simple palliation a corset which lessens the exaggerated lordosis 
and provides pressure over the trochanters is of some service in the 
double dislocation. Some form of brace attached to the shoe by which 
the weight of the body is supported on a perineal strap as described in 
the treatment of the convalescent stage of hip disease, and which ex- 
erts pressure on the trochanter may be employed in the single form 
supplemented by exercises and by massage. By such means the 
progress of the deformity may be checked and some improvement in 
the position and stability of the bone may be assured, although increase 
of the deformity may be expected when the treatment is discontinued. 
A " high shoe " to equalize the length of the limbs, to lessen the limp 
and to prevent permanent distortion of the spine is indicated also. 
Over-exertion and laborious occupations should be avoided. This is 
of especial importance during childhood and adolescence when the ten- 
dency toward an increase of the disability is most apparent. 1 

Coxa Vara. 

Synonyms. — Depression or incurvation of the neck of the femur. 
Bending of the neck of the femur. 

The character of this deformity is indicated by the synonyms, while 
the term coxa vara signifies that its causes and effects are similar to 
those of genu valgum and varum, the more common distortions of the 
lower extremities. 

Genu valgum and varum are common in childhood, but rarely de- 
velop in adolescence. Coxa vara is, in comparison, not only an infre- 
quent deformity, but it is peculiar also in that it more often appears in 
later childhood or adolescence than at the earlier period, doubtless 
because the neck of the femur is, at the age when rhachitic distortions 
are common, very short and is relatively stronger than the shaft, while 
in adolescence the conditions may be reversed. 

1 The bibliography of the subject may be found in the volumes of the Zeits. fin* 
Orth. Chir. 



ETIOLOGY. 



393 



The distortions at the knee are self evident, but the neck of the 
femur is concealed from view, thus the diagnosis of coxa vara may be 
somewhat difficult ; and in fact, it is only in very recent years that its 
symptoms have been recognized. Fiorani l first described the deform- 
ity as it had been observed by him in children, but E. Miiller 2 first 
called attention to the affection as one of the deformities of adolescence, 
which, until that time, had been mistaken for hip disease. 

Pathology. — The term coxa vara should not be applied to depres- 
sion of the neck of the femur that may be secondary to destructive 
disease ; for example, to osteomyelitis, arthritis deformans and the 
like, but it should be reserved for 

cases of simple local deformity. Fig. 272. 

In most instances the deformity 
affects the neck as a whole, in 
others it is most marked at the 
epiphyseal junction. A number 
of specimens have been examined 
but no changes, other than such as 
might be caused by the deformity 
itself, have been found. These 
are, in brief, congestion and soften- 
ing of the bone, and evidences of 
irritation within the joint during 
the progressive stage of the defor- 
mity and the general adaptive 
changes in all the components of 
the joint that always accompany 
displacement or distortion. 

Etiology. — Some writers as- 
sume that the weakness of the 
neck of the femur that induces 
the deformity is the result of local 
disease such as so-called local 
rickets, or local osteomalacia. 
This is however simply a conve- 
nient hypothesis. Others believe 

the deformity to be symptomatic of late rickets; but evidence of general 
rhachitis is almost never present in the ordinary type of cases. 

Coxa vara is one of the group of static deformities of the lower ex- 
tremity caused by a disproportion between the strength of the sup- 
porting structure and the burden that is put upon it. The support 
may be disproportionately weak because of inherited delicacy of struc- 
ture, or it may be weakened by injury or by disease, or over-burdened 
by weight or strain. 

Mechanical Predisposition to Deformity. — In many cases 
the predisposition to deformity is the result of a lessened angle of 

l Gazetta degli Ospitale, Xos. 16-17, 1881. 

2 Beitrage zur Klin. Chir., 1889, Bd. 4. 

3 Humphrey, Jour. Anat. Phvs., Vol. XXIII., p. 236. 




Section of the upper extremity of a norma! 
femur at eight years of age ; angle formed by the 
neck with the shaft 140 degrees. In the norma! 
subject the neck of the femur projects slightly for- 
ward (12 degrees), and upward to form an angle 
with the shaft of about 125 degrees. In childhood 
this angle is usually somewhat greater, and in 
later years it may be" somewhat less than 125 de- 
grees"; in fact a variation between 110 and 140 de- 
grees may be within the normal limit. 3 



394 COXA VARA. 

the femoral neck. This slight and predisposing depression which ap- 
pears to be, in many instances, the effect of early rhachitis, becomes 
exaggerated to deformity during later childhood or adolescence. The 
importance of this mechanical factor in the etiology was demonstrated 
to me by the investigation of a number of cases of simple fracture of 
the neck of the femur in childhood. In these cases the neck of the 
femur was, by the original injury, somewhat depressed, and although 
complete functional recovery followed, yet in a number of the cases, 
progressive deformity, attended by the symptoms of typical coxa vara, 
resulted. This could be explained only on the theory that the lessened 
angle, subjecting the part to greater strain, was the predisposing cause 
of the later disability. Other factors in the etiology may be general 
weakness, incident to rapid growth, direct injury or the strain of occu- 
pation. 1 

In this connection it may be stated that fracture of the neck of the 
femur in childhood may cause a deformity which in the absence of a 
history could not be distinguished from the ordinary form of coxa vara, 
of which in fact, it is the traumatic form. (See fracture of the neck of 
the femur.) 

Statistics. 

The deformity is far more often unilateral than bilateral and more 
than three-fourths of the cases are in males. In a total of 109 cases 
collected from the literature, including 39 personal observations, 83 
were in males and 26 in females ; 85 were unilateral and 24 were bi- 
lateral. The more important details in the 39 cases that have come 
under my observation, are presented in the accompanying table. 

The points of especial interest may be summarized as follows : In 
about one-third of the cases there was a distinct history of rhachitis 
in infancy. The ages at which the symptoms became noticeable ap- 
peared to be as follows : 

Adolescents, 12 to 17 20 

Later childhood, 5 to 11 13 

Early childhood, less than 5 5 

Unknown 1 

Total .39 

29 of the patients were males, 10 were females. In 33 cases the 
deformity was unilateral, in it was bilateral. In 34 cases the neck 
of the femur was distorted in a direction backward as well as downward, 
in 2 directly downward, in 3 forward and downward. In each case 
of the last group the deformity was bilateral. (See table, page 395.) 

Symptoms. 1. Mechanical Effects. — The character of the 
symptoms may be explained by a description of the distortion and 
of its direct effects upon the function of the joint. When the neck of 
the femur is depressed, for example, to a right angle with the shaft, 

1 One case of congenital coxa vara has been reported by Kredel (Cent, fur Chir., 
N. 42, 1896). Depression of the neck of the femur in congenital dislocation of the 
hip has been mentioned in the section on that affection. 



SYMPTOMS. 



395 















Hi 


Z i 

"if 




■ ^ 


Name. 


Date. 




"5 




Duration. 


— .2 i 


■f •" 


a 


^oi-H 








c3 






'-3 o-OTJ 


,_ a 


t x c 


III 






* 




a5 

fcc 




dist 

war 
\v:ir 


a be 


~ 5 






CO 


33 


< 




R 


< 


< 


w 


1 Nelson 


Oct. 1896 


F. 


R. 


IVz 


6 months 


Post. 


A 


% 


Yes 


2 Van Orden 


June 1896 


M. 


R. 


4 


1 year 


Post. 


% 


No 


3 Zeltermann 


Jan. 1898 


M. 


R. 


7 


6 months 


Post. 


/i 


X A 


Yes 


4 Vitt 


Mar. 1897 


M. 


L. 


7 


6 months 


Post. 


l 


l 


Yes 


5 Tuit 


Julv 1899 


F. 


L. 


7^ 


6 months 


Post. 


V* 


% 


Yes 


6 Seeger 


Mar. 1897 


F. 


L. 


8 


2 years 


Post. 


1 


i 


No 


7 Kose 


Jan. 1888 


F. 


D. 


8 


3 years 


Post. 


— 


— 


No 


8 Cohen 


June 1898 


M. 


R. 


8 


6 months 


Post. 


£ 


% 


Yes 


9 Kebesky 


Aug. 1900 


M. 


L. 


8 


6 months 


Down'd 


X A 


Yes 


10 Dengher 


July 1900 


M. 


R. 


8 


1 year 


Down'd 


A 


A 


Yes 


11 Hirsch 


Mar. 1897 


M. 


D. 


9 


2 years 


Aut. 






Yes 


12 Reardon 


Mar. 1898 


M. 


D. 


11 


6 years 


Ant. 


— 


— 


Yes 


13 Beckruyer 


Mar. 1895 


M. 


D. 


11 


8 years 


Post. 


— 


— 


Yes 


14 Brill 


Mar. 1894 


M. 


R. 


11 


1 year 


Post. 


l 


l 


No 


15 Greer 


Jan. 1896 


M. 


L. 


12 


8 years 


Post. 


l 


l 


Yes 


16 Thomas 


Mar. 1898 


F. 


D. 


12 


1 "year 


Ant. 


R. % 


% 


Yes 


17 Abrams 


Mar. 1898 


F. 


R. 


13 


10" years 


Post. 


2 


72 


No 


18 Rutschmann 


July 1896 


M. 


R. 


13 


6 months 


Post. 


y % 


No 


19 Fraad 


Nov. 1894 


M. 


R. 


13 


1 year 


Post. 


M 


34 


No 


20 Shandlev 


Dec. 1898 


F. 


R. 


13 


1 year 


Post. 


a 


t 





21 Skidmore 


Nov. 1899 


M. 


L. 


13 


3 years 


Post. 


Vi 





22 Cords 


Mav 1900 


M. 


R. 


14 


3 months 


Post. 


% 


134 


Yes 


23 Cunningham 


May 1897 


F. 


L. 


14 


1 year 


Post, 


% 


i% 


No 


24 Herbert 


Apr. 1897 


M. 


R. 


14 


6 months 


Post. 


i 


i 


No 


25 Bruning 


Oct. 1897 


M. 


R. 


15 


2 months 


Post. 


A 


l 


No 


26 Betz' 


June 1892 


M. 


R. 


15 


1 year 


Post. 


H 


3 


No 


27 Law son 


Oct. 1897 


M. 


R. 


15 


1 year 


Post. 


^ 


IK 


No 


28 Rose 


Jan. 1896 


M. 


L. 


15 


14* months 


Post. 


% 


No 


29 Allen 


Apr. 1897 


M. 


L. 


16 


1 month 


Post. 


1 


VA 


No 


30 Puckhaber 


June 1893 


M. 


D. 


16 


S months 


Post. 




- 


Yes 


31 Gieger 


Mav 1900 


M. 


L. 


16 


6 months 


Post, 


V* 


Vi 


No 


32 Schade 


Julv 1898 


M. 


L. 


16 


18 months 


Post. 


1 


l 





33 Morris 


Jan. 1900 


M. 


R. 


17 


6 months 


Post. 


M 


>2 


No 


34 Jocker 


Dec. 1899 


M. 


L. 


17 


1 month 


Post, 


A 


No 


35 Beck 


Julv 1898 


F. 


R. 


17 


1 year 


Post. 


i 


1% 


No 


36 Zimmermann 


Oct" 1896 


M. 


R. 


17 


13 months 


Post. 


2f4 


No 


37 Fessner 


Mar. 1894 


M. 


L. 


17 


6 months 


Post. 


Z A 


No 


38 Enderlich 


Jan. 1897 


F. 


R. 


i 22 


1 year 


Post. 


% 


l 


No 


39 Adult 


Mar. 1896 


M. 


R. 


1 36 




Post. 




l% 


No 



the trochanter is elevated to a corresponding degree above Xelaton's 
line and forms a noticeable projection as contrasted with the normal 
contour (Fig. 276), a projection that becomes more marked when # the 
thigh is flexed and addncted. (Fig. 275.) In most instances the 
neck is displaced backward as well as downward, following the line of 
least resistance, and as the head of the bone remains in the acetabulum 
the trochanter is thrown forward and the limb is rotated outward. 
The ability to abduct the thigh is dependent upon the length and upon 
the upward inclination of the femoral neck (Fig. 154) ; when, there- 
fore, this inclination is diminished the range of abduction is lessened, 
in part by the greater tension that is exerted upon the lower portion 
of the capsule, in part by the direct contact (Fig. 273) of the rim of 
the acetabulum with the neck and trochanter and in part by the 
adaptive contractions that always accompany displacements of this char- 
acter. It is evident also that the distortion of the neck backward 
and downward changes the relation of the acetabulum to the head of 
the bone, so that abduction or flexion tends to displace it from its 
socket. Thus the range of abduction, of inward rotation and of flexion 
is limited, while that of adduction, outward rotation and extension, 
may be increased. 



396 



COXA VARA. 



There is actual shortening of the limb dependent upon the upward 
displacement of the shaft of the femur; this is not often more than an 
inch in the ordinary type of adolescent deformity, but the apparent 
shortening, caused by the adduction and the accommodative upward 
tilting of the pelvis, may be extreme, from two to three inches is not 
uncommon. (Fig. 276.) 

2. Physical Effects. — The symptoms of coxa vara of the ordinary 
form, are : Discomfort, awkwardness, limp, shortening, atrophy, limita- 
tion of motion, deformity. 

Coxa vara is a more disabling deformity than genu varum or val- 
gum and its attendant symptoms of discomfort, weakness and pain, 
are, as a rule, more marked. This is explained by the fact that in 



Fig. 273. 




Skiagram of coxa vara, deformity most marked at the epiphyseal junction. This illustrates the me- 
chanical limitation of abduction caused by the deformity, and the compensatory tilting of the pelvis. 
The patient is shown in Fig. 276. 

coxa vara, the head of the bone is in part displaced (Fig. 2*74) from 
the acetabulum, while in the deformities at the knee the joint surfaces 
remain in practically normal relation to one another. 

The symptoms of unilateral coxa vara vary with the degree and with 
the duration of the deformity. The patient usually complains of sen- 
sations of stiffness and weakness, referred to the thigh. These are 
more noticeable on changing from a position of rest to one of activity 
and at times, particularly after over-exertion, there may be actual pain. 
By far the most important symptom and the one that almost always 
induces the patient to seek treatment, is the limp. This limp accom- 
panied, as it usually is, by outward rotation of the foot, resembles that 
caused by fracture of the neck of the femur. On physical examina- 



OTHER VARIETIES OE COXA VARA. 



397 



tion the actual shortening, explained by the elevated and prominent 
trochanter and the peculiar unequal limitation of motion, will make the 
diagnosis clear. In some instances there may be a slight degree of mus- 
cular spasm and there is usually some atrophy of the muscles of the thigh. 

Bilateral Coxa Vara. — If the deformity is bilateral its effect upon the 
gait and attitude is more marked. The gait is extremely awkward, 
resembling somewhat that of knock knees, for the limitation of abduc- 
tion forces the patient to sway the body from side to side in order that 
the legs may pass one another, and if the deformity is extreme the limbs 
may be crossed over one another, so that locomotion may be difficult. 
Bilateral coxa vara is not 

infrequently accompanied Fig. 274. 

by other deformities, as, 
for example, knock knee or 
flat foot. (Fig. 277.) 

Other Varieties of 
Coxa Vara. — In rare in- 
stances the neck of the femur 
may be depressed directly 
downward or even down- 
ward and forward. In the 
latter instance the effect of 
the deformity upon the func- 
tion of the joint is some- 
what different from that of 
the ordinary type. Abduc- 
tion is limited as in the 
common form, but inward 
rotation replaces outward 
rotation and extension is 
limited in place of flexion. 
This type of deformity is 
almost always bilateral. It 
is accompanied, usually, 
by slight permanent flex- 
ion of the thighs ; thus the 
lumbar lordosis is exaggerated, whereas, in the ordinary form, it is 
usually lessened. 

This description applies to the ordinary types of the deformity 
as it is seen in later childhood and in adolescence. It undoubtedly 
occurs in early life, but it is masked by the more noticeable dis- 
tortions of other parts, and as an isolated deformity that demands 
treatment, it is rare. One case was observed by the writer in a 
rhachitic child two and one-half years of age. The symptoms, though 
slight, were typical, and the diagnosis was confirmed by a Roentgen 
picture. In other cases seen in later childhood, the history of more or 
less discomfort for many years, seemed to indicate that the deformity 
was caused directly by rhachitis. 




Cross section of the pelvis and the deformed femur. A 
scheme to show the effect of the deformity in limiting ab- 
duction of the limb. The dotted outline shows the normal 
relation. 



398 



COXA VARA. 



In the majority of cases the symptoms begin insidiously although 
in many instances they may be ascribed to injury or to over-exertion. 
If the affection begins in adolescence and is untreated, the period of 
discomfort during which the depression of the neck may be assumed 
to be progressive, is from one to three years ; but if the deformity 
appears at an early age, the symptoms, though remittent in character, 
may continue indefinitely. When the resistance of the compressed bone 



Fig. 275. 



Fig. 276. 





Coxa vara, showing prominent trochanter. 



Case II. Shows the tilting 
of the pelvis and the apparent 
shortening of the leg in unilat- 
eral coxa vara.- Actual short- 
ening % inch ; apparent short- 
ening 2% inches. See skiagram 
(Fig. 273). 



becomes sufficient to insure stability, the discomfort ceases and the dis- 
ability becomes less marked, as Nature accommodates the mechanism to 
the new condition s.J 'C^'^ 

Diagnosis. — In most instances diagnosis may be easily made, and 
yet coxa vara is very often mistaken for hip disease ; in fact we are 
indebted to this mistake for most of the specimens of the deformity 
that have been described. The essential differences between the two 






TREATMENT. 



399 



are as follows : In tuberculous disease of the hip the motions of the 
joint are limited in every direction by reflex muscular spasm, and as a 
rule, other evidences of the character of the disease are apparent. Coxa 
vara is a simple deformity ; reflex muscular spasm is absent, except 
during exacerbations due to injury or over-strain, and movement is not 
limited in all directions, but only in abduction, flexion and inward 
rotation when the deformity is of the ordinary type. Actual short- 
ening is a late symptom of hip disease, while it is present from the 
very onset of coxa vara. It is a shortening explained by the eleva- 
tion of the trochanter above JSelaton's line, while such elevation in hip 
disease is a sign of de- 
struction, either of the Fig. 277. 
head of the bone or of a 
part of the acetabulum. 

The deformity might 
be readily mistaken for 
congenital dislocation of 
the hip, particularly of the 
anterior variety, but this 
would be excluded by the 
history, since coxa vara is 
:an acquired deformity. 
The diagnosis between the 
two affections may be 
easily made on the physi- 
cal signs alone. In conge- 
nital dislocation, if the leg 
be flexed and adducted to 
its extreme limit, the head 
and neck of the displaced 
bone can be distinguished 
beneath the distended 
tissues of the buttock. 
In coxa vara, nothing but 

the prominent trochanter can be made out on similar manipulation, while 
the abnormal mobility, characteristic of the dislocation, is absent. 

Treatment. — If the deformity were discovered in the early stage, 
one might hope to check its progress by a change in the surroundings 
and occupation of the patient. Standing, particularly in the attitude 
of rest, which throws additional weight upon the weakened part, should 
be avoided, and work of any kind that induces the familar symptoms 
of strain should be discontinued. As much time as possible should be 
spent in the open air, and diet and proper therapeutic remedies should 
be employed if evidence of constitutional weakness or rhachitis is pres- 
ent. Locally massage of the limbs and joints and forcible manipula- 
tion, with the aim of overcoming as much of the adduction as may de- 
pend upon the secondary changes in the soft parts, should be employed, 
reinforced by regular gymnastic exercises of the legs, with the object 




Double coxa vara of advanced degree, showing the involun- 
tary crossing of the legs in flexion. 



400 



COXA VARA. 



of improving the circulation upon which the repair of the weakened 
bone depends. 

In most instances of unilateral deformity temporary support is indi- 
cated. A perineal crutch (Fig. 204) or, if the circumstances of the 
patient permit, one of the convalescent hip 
splints that allows motion at the knee, may p IG 279. 

be used. (Fig. 205.) With support dur- 
ing the time of greatest strain, that is, 
when continuous walking or standing may 
be required, combined with proper exer- 
cises and massage, the weak part may be- 

Ftg. 278. 





Unilateral coxa vara, showing the 
effect of slight depression of the neck 
of the left femur upon the attitude. 
(See Fig. 279.) 



The patient, Fig. 278, eight months 
after cuneiform osteotomy. An abso- 
lute cure both as regards symptoms and 
deformity. See skiagram (Fig. 280). 



come sufficiently strong to perform its function in a year or more, but 
supervision will be necessary for a much longer time. 

Operative Treatment. — When the deformity has advanced so that the 
leg is permanently adducted, operative treatment is indicated. 

Linear Osteotomy. — The simplest and most efficient means of 
overcoming the adduction in older subjects is linear osteotomy of the 






OPERATIVE TREATMENT. 



401 



shaft of the femur just below the trochanter minor. This may be per- 
formed by the subcutaneous method, as in the correction of the de- 
formity of hip disease. When the bone has been divided the shaft is 
rotated inward until the foot is brought to the normal attitude and it 
is then abducted to the normal limit ; in this attitude a plaster spica 
bandage is applied reaching from the axilla to the toes. 

If the deformity is bilateral it is often sufficient to operate on the 
leg which is most affected. When the fracture is consolidated, mas- 
sage, exercises and support are employed as has been described. It 
may be assumed that the increased blood supply necessitated by the 
repair of the injury will aifect favorably the weakened bone as well. 

Fig. 280. 




Skiagram of patient, Figs. 278 and 279. Illustrating the effect of the operation in replacing the 
neck of the femur in its normal position. 



The final result in two cases, in which the operation was performed by 
the writer, was very satisfactory. 

Cuneiform Osteotomy. — In younger patients the deformity may 
be remedied and its progress checked by removal of a cuneiform sec- 
tion of bone from the upper extremity of the shaft at the level of the 
trochanter minor. (Fig. 281.) In childhood the neck of the femur is 
short and the strain to which it is likely to be subjected slight, thus op- 
erative treatment may be indicated as a prophylactic measure while in 
adolescence operative treatment may be deferred until the progression 
of the deformity has ceased. 

^In the technique of this procedure there are several points of im- 
portance. First, all restriction of abduction, of ligamentous or mus- 
26 



402 COXA VARA. 

cular origin, must be overcome by vigorous manipulation before the 
operation on the bone, otherwise it will be difficult to bring the two 
fragments into proper apposition. The base of the wedge should be 
about three-quarters of an inch in breadth, directly opposite the tro- 
chanter minor ; the upper section should be practically at a right angle 
with the shaft, the lower being more oblique. (Fig. 281, 2.) The cor- 
tical substance on the inner aspect of the bone should not be divided, 
but, reinforced by the cartilaginous trochanter minor, should serve as a 
hinge on which the shaft of the femur is gently forced outward, until 
the opening is closed by the apposition of the fragments after the up- 
per segment has been fixed by contact with the margin of the acetab- 
ulum (Fig. 281,3); thus the continuity of the bone is preserved. The 
leg is then held in the attitude of extreme abduction, by means of a 
plaster spica bandage, which should include the foot also, until the union 
is firm. 

The opportunity for treatment of coxa vara, in earliest childhood, is 
rarely offered. It is usually the direct result of rhachitis and in the 
early stage, at least, it is probably accompanied by other rhachitic dis- 
tortions. It would be well, therefore, to examine the hip joints of 
rhachitic children, especially those who present the deformity of genu 
valgum with reference to this distortion. 1 



FRACTURE OF THE NECK OF THE FEMUR. 
Traumatic Coxa Vara. 

Fracture of the neck of the femur in childhood, although until re- 
cently unrecognized, is by no means an uncommon accident, since 
seventeen cases have come under the writer's observation during the 
past nine years. 

Fracture of the neck of the femur in childhood, however, differs 
markedly in its symptoms and in its effects from that in later life. 
In childhood the immediate effects of the injury are far less disabling 
and the patient is often able to walk about within a few days after the 
accident, from which it may be inferred that there is, in many instances, 
a bending and breaking of the neck without actual separation of the 
fragments. During the period of repair the limp and attendant dis- 
comfort are usually mistaken for symptoms of hip disease. 

The diagnosis is usually simple. In all the cases there is a history 
of injury, usually a fall from a height, which confined the patient to 
the bed for several days or weeks. On physical examination shorten- 
ing of half an inch to an inch is found, explained by the corresponding 
elevation of the trochanter. Motion in the joint is more or less re- 
strained by voluntary and involuntary contraction of the muscles, but 
this restriction is much more marked in flexion, abduction and inward 
rotation than in other directions ; a limitation explained by the nature 

'-The bibliography of the subject, to the extent of 127 references, may be found in 
a recent article by Wagner in Zeits. fur Orth. Chir., Bd. VIII. , H. 2, 1900. 



TRAUMATIC COXA VARA. 



403 



of the displacement, the neck of the bone having been forced down- 
ward and backward. 

The immediate effect of the injury is, as has been stated, less marked 
than in the adult, but the tendency of the deformity is to increase in 
later years, because the right-angled relation of the neck to the shaft 
exposes it to greater strain. In a number of the patients examined 
several years after the injury, there was an increase of the actual 
shortening combined with permanent adduction. At this time the de- 
formity could not have been distinguished, except for the history, from 
the ordinary coxa vara of a rather extreme degree. 

The treatment of the fracture of the neck of the femur, if the diag- 
nosis is made immediately after the accident, should include an attempt 



Fir;. 281, 





1, the normal femur ; 2, depression of the neck of the femur— coxa vara ; A, a wedge of bone has 
been removed ; 3, abduction of the limb first fixes the upper segment by contact with the rim of the 
acetabulum, then closes the opening in the bone ; 4, replacement of the limb after union is completed 
elevates the neck to its former position. 

to replace the neck in its proper relation w T ith the shaft in order that 
subsequent deformity may be prevented. This may be accomplished, 
if at all, by forcing the limb into abduction while traction is exerted, 
and in this position a plaster bandage, reaching from the axilla to the 
toes, should be applied. 

After consolidation of the fracture a traction hip splint may be worn 
for several months or until complete repair has taken place. Massage 
and forcible manipulation, if limitation of motion remains, combined 
with the avoidance of over-strain, may prevent the increase of the de- 
formity. Otherwise the neck of the femur should be replaced in its 
normal position by the removal of a sufficient wedge of bone from the 



404 



COXA VARA. 



base of the trochanter as described under the treatment of simple coxa 
vara. (Fig. 281.) 

Traumatic Separation of the Epiphysis of the Head of the Femur. — 
As has been stated, in traumatic depression of the neck of the femur 
the bone breaks or bends at about the center of the neck, which in child- 
hood is but little more than an inch in length. In exceptional cases 
the head of the femur may be separated at the epiphyseal line. This 
disjunction is more likely to occur in adolescence and particularly in 
subjects suffering from coxa vara in the early stage. Thus sudden 
disability, following slight injury, in an adolescent who has complained 
of discomfort and limp for some time before and who presents on ex- 
amination the signs of depression of the neck of the femur, would lead 
one to consider the possibility of this accident ; but the diagnosis could 
be established only by a Roentgen picture or by operation. 1 

The treatment is similar to that of fracture, but the functional de- 
rangement of the joint is likely to be greater for the reason that the 
articulating surface of the head of the femur is involved. 2 

^prengel, Archivf. Klin Chir., Bd. 47, S. 805, 1898 ; Clarke, Lancet, Oct. 27, 1900. 
2 Whitman, The Medical Kecord, July 25, 1893 ; Annals of Surgerv, June, 1897. 
and February, 1899. 



CHAPTER XV. 

DEFORMITIES OF THE BONES OF THE LOWER 
EXTREMITY. 

Of the distortions of the lower extremity bow leg and knock knee 
are by far the most common, comprising about 15 per cent, of the total 
cases in orthopaedic clinics. Of the two, bow leg is the more frequent 
in all tables of statistics, and it is probable that the proportion of bow 
leg to knock knee is much larger than would appear from the hospital 
records ; for genu valgum is generally recognized as a serious deform- 
ity, while bow leg is known to be of little consequence except from the 
aesthetic standpoint, so that its rectification is more often trusted to the 
power of nature. 

Both deformities appear to be more common in male than in fe- 
male children, a fact explained perhaps by the greater weight and the 
greater susceptibility of the former. But here again statistics may be 
influenced somewhat by the fact that bow legs are considered to be of 
more consequence to the boy than to the girl because of the conceal- 
ment that the skirts will insure, if the distortion is not outgrown in 
childhood. 

Statistics. — The relative frequency of the two deformities may be in- 
dicated by the statistics of the Hospital for Ruptured and Crippled for 
the past ten years. During this time 5,441 cases were recorded, 3,452 
cases of bow legs (63.4 per cent.), 1,989 of knock knees (37.6 per cent.). 
Of the 3,452 cases of bow legs, 2,030 were in males (58.8 per cent.) and 
1,422 were in females (42.2 per cent.). The 1,989 cases of knock 
knees were more evenly divided between the sexes, 1,024 being in 
males (51.4 per cent.) and 965 in females (48.6 per cent.). 

Bow Legs. 



Year. 



1 
2 
3 

4 
5 
6 
7 
8 
9 
10 



1899 
1898 
1897 
1896 
1895 
1894 
1893 
1892 
189] 
1890 



No. cases. Males. 



400 
406 
467 
356 
336 
310 
262 
306 
303 
306 



236 
255 
268 
200 
200 
170 
157 
189 
174 
181 



3,452 



2,030 



Females. 


Over 21. 


164 


o 


151 





199 


4 


156 





136 


9 


140 


T 


105 


3 


117 


1 


129 


1 


125 


1 


1,422 


13 



Over 14. 

5 

2 
1 
1 
1 
2 
3 
2 
1 
3 
21 



406 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



Knock Knees. 





Year. 


No. cases. 


Males. 


Females. 


Over 21. 


Over 14. 


1 


1899 


202 


120 


82 


1 


4 


2 


1898 


233 


135 


98 





11 


3 


1897 


222 


120 


102 


2 


5 


4 


1896 


232 


101 


131 








5 


1895 


210 


109 


101 





2 


6 


1894 


212 


86 


126 


o 





7 


1893 


162 


80 


82 


1 


2 


8 


1892 


168 


89 


79 


8 


2 


9 


1891 


189 


92 


97 


1 


2 


10 


1890 


159 


92 


67 


3 


3 




1,989 


1,024 


965 


16 


29 



It will be noted that 45 of the cases of genu valgum were in patients 
more than 14 years of age, as compared with 34 cases of adolescent or 
adult bow legs. The writer's personal experience in the clinic enables 
him to state that a large proportion of the cases of genu valgum actu- 
ally developed or increased to an extent demanding treatment during 
adolescence, while most of the cases of bow leg deformity in patients 
more than 14 years of age had existed since early childhood or were 
the result of injury or disease. 

The Etiology of Genu Valgum, Genu Varum and of Other Dis- 
tortions of the Bones of the Lower Extremity. — The common pre- 
disposing cause of simple deformities and disabilities of the lower ex- 
tremities, in other words those not caused by local injury or local disease, 
is the erect posture, when for any reason the bones and the joints are 
unequal to the strain of locomotion and to the task of sustaining the 
weight of the body. 

i Time of Onset. — At two periods of life the deformities under con- 
sideration most often develop. The first is in early childhood, when 
the upright posture is first assumed ; the second is in adolescence, 
when the rapid growth and other changes incident to this period may 
lessen the stability of the supporting structures, and when the strain 
of laborious occupation may be added to that of the increasing weight 
of the body. 

The deformities of adolescence are, however, relatively insignificant 
in number compared with those of early childhood, for in childhood 
inherited weakness or weakness that is the direct result of malnutri- 
tion, at once develops into deformity under the strain of standing and 
walking. Thus, as a rule, the deformities under consideration first at- 
tract attention soon after the child begins to walk, and the patients are 
usually brought for treatment during the second or third year of life. 
If the deformities are severe, the body usually presents the evidences 
of general rhachitis ; in other instances the distortion of the legs is 
the only sign of its presence, and in other cases there may be no evi- 
dence whatever of malnutrition or disease. 

Predisposition to Deformity. — It is not always easy to explain 
why weak legs bend in one way rather than in another. In some 



ETIOLOGY. 



407 



instances it is probable that a slight degree of deformity is present 
before the child begins to walk. For example, a slight outward bow- 
ing of the legs is said to be common in early infancy, and the use of 
heavy diapers might favor a continuation of the distortion. Knock 
knee may be induced, apparently, by holding the infant on the arm 
with the knees pressed against the chest, and certain cases of knock 
knee and bow leg combined appear to be caused directly by this manner 
of carrying the infant habitually upon one arm. 

The legs of rhachitic children, who have never walked, are often 

Fig. 282. 




Habitual posture as a factor in the etiology of rhachitic bow leg. 



somewhat distorted and in many instances this may be explained by 
the habitual postures. (Fig. 282.) 

A moderate degree of bow leg is not infrequently seen in vigorous 
infants who stand and walk at an early age. Aside from the deter- 
mining curve in the bone that may be present before the child be- 
gins to walk, this predisposition toward bow leg may be explained, 
perhaps, by the fact that young infants often separate the feet widely 
in walking and the swaying of the body from side to side may tend to 
bend the legs outward. In weaker or less vigorous children a slight 
degree of knock knee is not uncommon, induced, it may be, by weak- 



408 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



ness or inactivity of the muscles, as a result of which the child stands 
with the knees somewhat flexed and pressed together, while the feet 
are separated and everted, an exaggeration of the so-called attitude of 
rest. 

Bow leg is not uncommon in adult life and it is popularly associated 
with strength and activity. Undoubtedly the attitudes of activity favor 
the production of bow leg rather than knock knee, so that this tradi- 
tion may have a foundation of truth. It is said to be common among 
those who ride constantly and it may be a direct result of injury or dis- 
ease of the knee joint, but it may be stated that well-marked bow leg 
in an adult is almost always a deformity that has existed since child- 
hood. This statement cannot be made of genu valgum, since it may 

develop or increase during ado- 

Fig. 283. lescence or even in adult life. The 

r ^ ----- — r x predisposing cause is weakness or 

overstrain, and as has been stated 
in the popular mind the deformity 
is characteristic of weakness. 
\ The Attitude of Rest. — Genu 

valgum is an exaggeration of what 
is known as the attitude of rest 
or relaxation, in which the weight 
of the body is thrown in great part 
upon the ligaments of the three 
joints of the lower extremity. In 
the attitude of rest the pelvis is 
tilted forward, the femora are ro- 
tated inward upon the tibiae and the 
feet are separated and everted, so 
that the greatest strain falls upon 
the inner side of the knees and of 
the feet. Thus, what is known as 
flat foot is often combined with 
knock knee; knock knee may cause 
flat foot, but more often the flat foot 
may induce knock knee, or both may 
be the effect of the same general cause. Genu valgum, in the slighter 
degree at least, may be induced directly by an improper attitude, but 
the attitude is, as a rule, the result of over-work to which the mechan- 
ism is subjected ; thus the knock knee of adolescence is so common 
among the bakers of Vienna, that " baker's knee " is there synonymous 
with genu valgum. 

Genu valgum may be secondary to distortion elsewhere. For ex- 
ample, compensatory knock knee is usually combined with extreme ad- 
duction of the thigh; it may be the result of the inactivity necessitated 
by the treatment of hip disease ; it may be a direct result of injury, and it 
is sometimes an accompaniment of osteomyelitis or osteoperiostitis of the 
tibia, which causes an overgrowth and abnormal lengthening of the leg. 




A type of deformity in which the prognosis as 
regards outgrowth is bad. 



THE 0U1GB0WTH OF DEFORMITY. 409 

The Outgrowth of Deformity. — In considering the treatment of 
the simple static deformities of the lower extremity which are usually 
the result of a temporary weakness of structure, one must first answer 
the question, "Will not the child outgrow it?" This belief in the 
spontaneous cure of deformity is very strong not only among the laity 
but among physicians as well ; and it rests upon the common observa- 
tion that crooked legs become straight, or at least less deformed, with 
the growth of the child. In fact if one were to judge from the general 
observation of the effect of growth upon the deformities of this class, or 
even from the tracings of the legs of rhachitic children taken from 
year to year, one might conclude that all deformities of this class might 
be safely left to themselves. As an illustration of positive evidence on 
the subject, the observations of Kamps, 1 on 32 cases of rhachitic dis- 
tortion of the lower extremity, may be cited. Four and one-half years 
after the cases were first seen and recorded, examination showed that 
75 per cent, were cured, 15.3 per cent, improved, while 9.7 per cent, 
were unimproved. His conclusions are that such deformities do not, 
as a rule, require special treatment in early childhood, but that after the 
age of six years the prognosis for spontaneous cure is unfavorable. 

Veit 2 photographed a number of rhachitic children seen in the sur- 
gical clinic of the University of Berlin, and after a lapse of two or 
three years made another series of photographs of the same patients, 
who had meanwhile received no treatment. His conclusions are simi- 
lar to those of Kamps, namely, that surgical treatment is not required 
for deformity of this character in children less than six years of age. 
In two classes of cases, however, the prognosis for spontaneous cure is 
not favorable, those in which the growth has been checked by the rha- 
chitic process, and in certain cases of extreme bow legs, "O" legs. 
(Fig. 283.) 

The rectifying force of nature acts in two ways. Assuming that the 
deformity reached its limit during the period of original weakness, it 
must of course become relatively less as the body increases 'in length 
and size. In fact the outgrowth of deformity has a direct relation to 
the rapidity of growth during the early years of childhood. The 
second manifestation of the power of nature is more positive. It may 
be assumed that when the deformity is progressive all the tissues are 
affected by the weakness, consequently the attitudes of the child are 
those that can be most easily assumed under the abnormal conditions. 
But when the primary cause of the weakness, in most instances rhachi- 
tis, is no longer operative, the muscles take on new activity and vigor 
and the actions and attitudes, in spite of the deformity, become ap- 
proximately normal. Then according to Wollf ? s law of transformation 
the internal structure of the affected bones begins to change to accom- 
modate itself to the new conditions of weight and strain induced by the 
change in action and attitude ; and to this rearrangement of the inter- 
nal structure, the external shape of the bones must conform in a grad- 
ual growth toward the normal contour. 

^eitrage zur Klin. Chir., Bd. 14, H. 1. 
2 Archiv f. Klin. Chir., Bd. 50, S. 130. 



410 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



On this theory, it is easily explained how the natural outdoor life 
of the country has long been celebrated as an effective treatment for 
this class of deformity. But it by no means follows that deformity 
is always outgrown, even under favorable conditions. Improper atti- 
tudes, that favor and cause deformity, are often observed among those 
who are free from weakness and disability and from the influences of 
unfavorable surroundings ; and such attitudes are of course more 
likely to persist in those who were once obliged to assume them be- 
cause of weakness and defor- 
Fig. 284. mity. Again, the weakness of 

structure or function may be 
an inherited peculiarity, or it 
may be induced by disease or 
by improper surroundings, in- 
fluences that may continue for 
many years and thus serve to 
check the natural tendency 
toward cure. 

The observations on the 
outgrowth of deformity have 
been confined, as a rule, to the 
period of childhood, and most 
often they have been made 
with reference to the more 
serious grades of distortion, 
which are the direct result of 
rhachitis. 

It must be borne in mind, 
however, that the true signifi- 
cance of these deformities in 
the adult must be judged from 
the sesthetic, rather than from 
the medical point of view, and 
although the extreme degrees 
of bow leg and knock knee are 
relatively rare yet in the minor 
grade both deformities are very 
common in adult males and 
in all probability in adult fe- 
males also. 
In 1887 the writer 1 noted among 2,000 adult males observed on 
the streets of Boston, 400 cases of bow leg and 32 cases of knock 
knee. One may assume then that the legs of about one adult male in 
five deviate more or less from the line of symmetry, a conclusion that 
has been confirmed by many subsequent observations. It may be ad- 
mitted that a certain number of the distortions under consideration are 
acquired during adolescence, but it is probable that the greater num- 
»N. Y. Med. Bee, July 30, 1887. 




Extreme deformities, the result of infantile 
rhachitis. The leg forms practically a right angle 
with the thigh. (See Fig. 288. ) 



GENU VALGUM. 



411 



ber of those that may be noted in walkers upon the streets represent 
the incomplete outgrowth of a deformity of childhood. 

The statement is often made that these distortions of the legs are 
common in childhood but rare in adult life. Just what the proportion 
may be in childhood it is impossible to say, but it is not likely to be 
greater than one in five. One must conclude that statistics, on which 
such statements are based, have been made up from the records of hos- 
pitals where it is extremely uncommon for an adult to apply for the 
treatment of bow leg, to which he has become accustomed since child- 
hood, unless the deformity is very extreme or is attended by pain. 

Granting that the power of nature is quite sufficient to modify, or to 
cure even the more extreme distortions of childhood, still it would seem 
that this natural force is often ineffective in completing the cure. There- 
fore in doubtful cases, at least, one should lend assistance in that class 
of patients likely to appreciate the advantage of symmetry over slight 
deformity, even though it be unattended by discomfort or disability. 

Genu Valgum. 

Synonyms. — Knock Knee, In Knee. 

In the erect posture the thighs, whose upper extremities are sepa- 
rated by the pelvis and by the projecting femoral necks, incline slightly 
inward to the knees, forming an angle at the knee, opening outward, 



Fig. 285. 



Fro. 286. 





Female. Male. 

The normal inclination of the femora. (Pfkifker. ) 



of about 172 degrees. This angle varies with the breadth of the pelvis, 
and it is therefore less in adult females than in males. (Figs. 285, 
286.) The internal condyle of the femur is slightly longer than the 
external, thus the inclination of the femur is compensated and the 
plane of the knee joint is horizontal. 



412 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



When the inward projection of the knees is increased to a noticeable 
degree the tibiae are no longer perpendicular, their upper extremities 
incline inward so that in the erect posture the feet are separated when 
the knees are in contact. (Fig. 287.) In the slighter grades of knock 
knee, which are due in great degree to laxity of the ligaments, the de- 
formity is apparent only when the weight of the body is borne, but in 
more marked cases, although the distortion is increased by the weight 
of the body, it can not be overcome when this is removed because it 
depends upon actual changes in the shape of the bones themselves. 

Fig. 287. 




Adolescent knock knees. Deformity most marked in the tibiae. (See Fig. 290.) 

As has been stated, the normal inward inclination of the femur is 
compensated by the greater length of the internal condyle, and in the 
deformity of knock knee the plane of the knee joint is still preserved 
by an apparent elongation of the inner condyle. Formerly it was sup- 
posed that there was an actual over-growth of this part of the epiphysis, 
which caused the deformity, but the observations of Mickulicz and 
Macewen have shown that this apparent lengthening is in reality due, 
in great part, to a deformity of the lower extremity of the shaft of the 



GENU VALGUM. 413 

femur, which is so bent that the epiphyseal line has an increased obli- 
quity. And the hypothesis that bone grows more rapidly when relieved 
from weight and strain has been disproved by Wollf, who has shown 
that changes in the bones are the result of accommodation to altered 
function and attitude. (See page 190.) The deformity is not limited 
to the femur ; in most instances there is a similar, although usually 
slighter, irregularity in the epiphyseal line of the upper extremity of 
the tibia, the shaft being so bent that when it is placed in the perpen- 

Fig. 288. 




Skiagram of Fig. 284 showing the deformity to be due to distortions of the diaphyses of the bones 
while the epiphyses are practically normal. 

dicular position its internal condylar surface is higher than the external. 
(Fig. 288.) 

Changed Relation of the Femur and Tibia. — In addition to 
the direct deformities of the bones there is a change in the relation of 
the femur to the tibia. The former is rotated inward and the latter is 
rotated outward. In some instances there is also a certain degree of 
over-extension at the knee. This is more often observed in the ado- 
lescent type in which there is laxity of the ligaments, but in the ordi- 
nary form of rhachitic knock knee in childhood, the habitual attitude 
is one of slight flexion at the knees and in extreme cases there may 



414 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



Fig. 289. 



be actual limitation of the range of extension at the knee, and at the 
hip as well. 

The Accommodative Attitude. — When the limb is fully ex- 
tended, the deformity is most marked because the shortened ligaments 
and tissues on the outer aspect of the joint become tense, and because 
the outward rotation of the tibia is increased. As the leg is flexed the 
deformity lessens, and in the attitude of complete flexion it disappears. 
(Fig. 290.) This is explained by the fact that the posterior surface 

of the condyles is not affected by the 
deformity of the shaft, while the 
relaxation of the ligaments and the 
outward rotation of the femora al- 
low the tibiae to become parallel with 
one another. This explains the ha- 
bitual attitude of slight flexion which 
is so often assumed by patients 
who thus unconsciously accommo- 
date themselves to the deformity. 

Secondary Deformities. — 
The outward inclination of the leg 
throws more weight upon the inner 
border of the foot and tends to de- 
press it into the attitude of valgus. 
Thus knock knee in weak children 
is often accompanied by flat foot, 
but in the more extreme grades of 
deformity the efforts of the patient 
to compensate for the abnormal 
separation of the feet may result in 
habitual supination, in fact, con- 
firmed and extreme knock knee is 
often accompanied by a slight de- 
gree of varus that becomes very evi- 
dent after the correction of the de- 
formity by operation. Even in the 
mildest type of knock knee, this 
compensatory and conservative ef- 
fort of nature shown by the so-called 
pigeon-toed walk, may be the first 
symptom that attracts attention. 
Gait. — The gait of the patient with well-marked genu valgum is 
peculiarly awkward and shambling. The knees " interfere " and must 
be assisted, as it were, in the effort to pass one another in walking. In 
the slighter cases, the thigh is abducted and rotated outward at the mo- 
ment of passing its fellow, the movement being then reversed as it, in 
its turn, supports the weight ; but in the more severe type this voluntary 
effort of the muscles of the leg is not sufficient, and in addition, the 
body is swayed from side to side and the legs are alternately swung 
outward and lifted around one another. 




Deformity of the femur in genu valgum. 
(Mickulicz.) 



GENU VALGUM. 



415 



The deformity and the effects of the deformity on the gait and atti- 
tude are the most important symptoms, as of other distortions of simi- 
lar origin. The patient is, as a rule, easily fatigued, and pain during 
the progressive stage, referred to the inner side of the knee where the 
ligaments are subjected to continuous strain, is a common symptom, par- 
ticularly in the adolescent type of genu valgum. 

Unilateral Knock Knee. — This description refers particularly to the 
cases in which the deformity is bilateral. Not infrequently it is uni- 
lateral, the leg being so shortened by the distortion that a well-marked 
limp replaces the swaying gait. The pelvis is tilted toward the short 

Fig. 290. 




Adolescent knock knee, showing the disappearance of the deformity when legs are flexed. 

(See Fig. 287.) 



leg, while the body is inclined in the opposite direction, so that in cases 
of long standing, a permanent curvature of the lumbar spine may be 
present. 

Knock Knee Combined with Bow Leg and with General Rhachitic Dis- 
tortions. — Occasionally the unilateral knock knee may be accompanied 
by an outward bowing of its fellow ; and in the marked distortions of 
the lower extremity, that are the result of rhachitis, the bones may be 
twisted and bent in various directions, although the outward expression 
of the deformity may be genu valgum. For example, the femora may 
be bent forward and outward above, and inward and backward below, 
while the tibiae may be bent inward above, and outward and forward 
below. 

In other instances, especially in the slighter rhachitic deformities, an 
outward bowing of the tibiae may accompany a slight degree of knock 
knees, so that it is difficult to classify the deformity. 



416 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



In the more extreme deformities of the rhachitic type, the shape as 
well as the contour of the bones is modified, for example, the internal 
border of the tibia may become very prominent at its upper extremity, 
and may project beneath the skin like an exostosis. (Fig. 291.) A 
change in the contour of the fibula accompanies and corresponds to 
that of the tibia although it is, as a rule, much less pronounced. As 

Fig. 291. 




Knock knee and bow leg. 



has been stated, the internal structure or architecture of the affected 
bones is changed to accommodate the new static conditions, and ac- 
cording to Wollf the internal change precedes the external deformity. 
Pathology. — In knock knee due directly to rhachitis the changes in 
the bones and in the epiphyseal cartilages are characteristic of that af- 
fection, but in the milder grades of deformity, aside from the change in 
the contour of the bones, the transformation of the internal structure, 



EXPECTANT TREATMENT. 417 

and in some instances slight thickening or irregularity of the epiphyseal 
cartilage, there is little noteworthy change from the normal. (Fig. 289.) 
The tissues on the internal aspect of the joint are relaxed, those on the 
outer side, the lateral ligaments, the capsule and the biceps muscle, are 
contracted and resist the reduction of the deformity. In the interior of 
the joint slight changes in the articulating surfaces of the bones, and 
evidences of chronic irritation of the synovial membrane have been 
described. 

Measurements. — There are various methods of measuring the de- 
formity. One of the simplest and most practical is to trace the out- 
lines on paper, while the child is seated with the legs fully extended, 
the knees being sufficiently separated to allow the pencil to pass be- 
tween them. The increase of the deformity, dependent upon the lax- 
ity of the ligaments and upon the outward rotation of the tibiae, may 
be estimated by measuring the distance between the two internal mal- 
leoli when the patient stands, the knees being slightly separated as be- 
fore and comparing this measurement with that between the similar 
points in the tracing. In the early stage of progressive knock knee, 
particularly in the type not caused directly by rhachitis, laxity of liga- 
ments and the habitual assumption of the attitude of rest, will account 
for the deformity, which the patient may be able to overcome, in great 
degree at least, by voluntary effort. This voluntary control of the de- 
formity is very suggestive, as indicating certain factors in its etiology 
and the principles that should be followed in its treatment. 

Treatment. — The treatment of the deformity under consideration 
may be classified as : Expectant, mechanical, and operative. 

Expectant treatment should not be expectant in the sense that noth- 
ing is to be done to correct the deformity, but expectant in that more 
positive treatment by braces or by operation is delayed, or avoided if it 
prove to be unnecessary. 

During the expectant period the cause of the deformity, if it is consti- 
tutional, should receive proper dietetic or medicinal treatment as already 
described in the chapter on rhachitis. And, if possible, the direct ex- 
citing causes of the deformity must be removed, that is to say, the im- 
proper attitudes or, in the adolescent, the predisposing occupations 
should be discontinued. General massage of the limbs may be em- 
ployed with advantage ; in older children special exercises may be 
practiced, and in all cases, whether braces are used or not, direct 
manipulation of the distorted limbs is of the first importance. 

Manipulation. — In the slight degrees of deformity, more espe- 
cially of that type in which the distortion appears to be due to simple 
weakness rather than to rhachitis, the expectant treatment may be 
tested. The legs should be vigorously massaged at morning and night, 
and forcibly straightened. The latter procedure is conducted as fol- 
lows : the patient is seated in a chair, the limb being fully extended so 
that the deformity is made as extreme as possible. One hand then 
clasps the knee, the palm lying against its inner aspect ; with the other, 
the calf is grasped firmly and the leg is then gently straightened over 
27 



418 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



the fulcrum formed by the palm of the hand, and is held in the corrected 
position for a moment. This manipulation should be continued with 
gradually increasing force, although not to the extent of causing actual 
pain, for ten minutes, at least twice in the day and oftener if possible. 
Posture and Exercise. — It has been stated that genu valgum is 
often accompanied, especially in the rhachitic cases, by flat foot, while 
in another type the inversion of the feet, or in the more severe cases 
the actual fixed attitude of varus, indicates the effort of nature to with- 



Fig. 292. 



Fig. 293. 





The Thomas knock knee brace. 



Thomas knock knee braces with pelvic band. 



stand and to compensate for the deformity at the knee. This serves as 
an indication for making the soles of the shoes thicker on the inner 
side as in the treatment of flat foot, in order to throw the strain upon 
the outer border of the foot. The patient should be instructed to walk 
with the feet parallel with one another, and for older children the tip- 
toe exercises, in which the body is raised upon the toes as many times 
as the strength permits, or games or exercises in which the legs are 
extended should be encouraged. Such exercises are often efficacious 



MECHANICAL TREATMENT. 



419 



in the early stage of adolescent knock knee, for as has been mentioned, 
genu valgum is an exaggeration of the attitude of rest, therefore its 
progress should be checked by the assumption of the attitudes proper 
to activity. A careful record of the deformity should be kept during 
this tentative treatment and if it improves somewhat, one is justified 
in delaying the more radical measures. This question may be decided, 
as a rule, in three months, if instructions are faithfully followed. 

Fig. 294. 




^Modified Thomas knock knee braces applied. 

Treatment by Braces. — The most efficient brace in the treatment of 
genu valgum is the simple straight steel bar or splint extending from 
the trochanter to the heel of the shoe, without joint at the knee. The 
greater efficacy of the rigid bar as compared with the jointed brace is 
explained by the fact that the rectifying force acts constantly when the 
joint is fixed, and because, in many instances, the patient habitually 
flexes the knees so that direct pressure cannot be made upon the de- 
formity by a brace that allows this attitude. 



420 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



Fig. 295. 



The Thomas Brace. — The simplest and cheapest brace is that of 
Thomas, which consists of a light steel bar provided with a pad at its 
upper end for pressure against the trochanter, while the lower rounded 
extremity is turned inward at a right angle, to pass through the heel of 
the shoe. The knee is fixed by a posterior bar attached to a thigh and 
calf band, as illustrated in the figure. When the brace is applied the 
knee is drawn backward and outward and is attached firmly to the 
brace by a roller bandage. (Fig. 292.) 

In the more extreme cases in which the knees and thighs are ha- 
bitually flexed, the addition of a pelvic band attached to the uprights 

by a free joint at the hips, adds to the 
comfort and efficiency of the appara- 
tus, as the attitude of outward or in- 
ward rotation can be regulated by 
twisting the uprights slightly. Or 
the pelvic band may be divided and 
attached by means of straps on the 
front and back. The uprights may be 
bent somewhat inward at first, and as 
the legs become straighter they are 
straightened and finally bent slightly 
outward to allow for the over-correc- 
tion of the deformity. (Fig. 294.) 
Twice a day the braces should be re- 
moved to allow for massage, manipu- 
lation and for voluntary exercises of 
the legs. In most cases the braces are 
not employed at night, although the 
rectification of the deformity may be 
hastened by their constant use. 

If the deformity is unilateral so that 
a brace is required for one leg only, the 
other shoe should be raised by a cork 
sole about three quarters of an inch in 
thickness to make walking easier. 
Children soon become accustomed to 
the braces and walk easily in spite of 
the absence of joints at the knees. 
Another simple and efficient brace is that used at the Children's Hos- 
pital at Boston. (Fig. 295.) The upper part of the brace is turned 
backward and upward to lie against the buttock, and the feet can be 
rotated in or out by lengthening or shortening straps passing before 
and behind the body. Braces jointed at the knee are sometimes em- 
ployed, but they are, as a rule, ineffective except in the slighter cases 
in which the deformity depends upon laxity of ligaments rather than 
distortion of bone. 

Duration of Treatment by Braces. — The duration of the 
brace treatment depends, of course, upon the degree of deformity, the 




Long braces for genu valgum. (Bradford 

AND LOVETT.) 



OPERATIVE TREATMENT. 421 

age of the child and upon the efficiency of the apparatus. From six 
months to one year of treatment by this means is usually required. 
The cure is assured by the gradual adaptation of the parts to the 
new static conditions. The contracted tissues of the outer aspect of 
the joint become lengthened ; the lax ligaments on the inner side con- 
tract ; the internal structure of the condyles and of the adjoining dia- 
physis is gradually transformed and at the external contour of the bone 
becomes correspondingly straighter. When the braces are discarded, 
attention should be paid to the attitudes, and the exercises that have 
been mentioned should be continued in order that relapse may be pre- 
vented. 

The Plaster Bandage. — When the bones are yielding, as in the 
deformity due directly to rhachitis in young children, it may be cor- 
rected rapidly by the repeated applications of plaster bandages, the leg 
being straightened as far as possible without causing discomfort, at each 
sitting. This method is rarely employed except in dispensary practice. 

Operative Treatment. — Immediate correction of the deformity, when 
it is at all marked, is as a rule indicated after the age of four or five years. 
It is perhaps needless to remark that the necessity for operation im- 
plies neglect of proper preventive treatment or the failure of the 
manipulative and mechanical methods because of their improper appli- 
cation. While it is possible to correct deformity of the bone by me- 
chanical treatment in cases far beyond this limit of age, yet the time 
required and the discomforts of the treatment exclude it in all but very 
exceptional cases. 

Osteotomy. — At the Hospital for Ruptured and Crippled, osteotomy 
is invariably performed in the treatment of genu valgum by means of 
the small Vance osteotome, the so-called " subcutaneous osteotomy." 
(Fig. 262.) 

The limb having been prepared in the usual manner is semiflexed and 
the inner surface of the knee is placed on a firm sand bag. With the 
fingers the femur is firmly grasped just above the condyles so that its 
size and position may be accurately determined, and the sharp osteo- 
tome about the size of a lead pencil is forced with its cutting edge 
parallel to the axis of the thigh down to the bone, at a point about one 
and a-half inches above the external tuberosity. While it is held 
firmly in position against the bone it is turned to the transverse direc- 
tion and is then driven through the cortex. When it enters the 
medullary canal, as is made evident by the lessened resistance, it is 
partly withdrawn and moved slightly to one side and the other and 
driven through the cortical substance until by gentle force the bone 
may be fractured. The osteotome is then withdrawn, the minute 
wound is covered with a pad of dry gauze, or if the oozing is profuse 
it may be closed with a catgut suture. The deformity is then slightly 
over-corrected and a plaster spica bandage is applied. If the de- 
formity is double both limbs are operated upon at the same sitting. 

The plaster bandage is continued for from four to six weeks and it 
is then usually supplemented by a brace which may be worn with ad- 



422 DEFORMITIES OF BONES OF LOWER EXTREMITY. 

vantage for several months, because of the laxity of the ligaments of 
the knee joint which is usually present in extreme deformity of rha- 
chitic origin. In less marked cases, the support is unnecessary. Mas- 
sage and exercises during the stage of recovery should be employed if 
possible. 

In some instances the osteotomy of the femur may be performed 
from the inner side at the same level more conveniently, especially if 
the deformity is extreme. 

Incomplete osteotomy and fracture in the manner described has been 
employed at the Hospital for Ruptured and Crippled in a very large 
number of cases without a single unfavorable result. The discomfort 
is insignificant and confinement to the bed after the third day is un- 
necessary. 

Cuneiform Osteotomy. — In the more extreme cases of general 
rhachitic deformity of the lower extremity in which the tibia is im- 
plicated, it is sometimes necessary to remove a cuneiform section of 
bone from the inner side of the tibia just below the epiphysis in order 
to straighten the leg completely. In such cases it is better to perform 

Fig. 296. 



G rattan osteoclast. 



the second operation at a later time in order that the effect of the fem- 
oral osteotomy may be observed. In exceptional cases the deformity 
may be practically confined to the tibia ; in such instances it should be 
corrected by a primary cuneiform osteotomy. 

Osteoclasis. — Osteoclasis, by means of the Grattan osteoclast, is an 
effective operation. With this instrument the bone may be broken 
above the condyles at the desired point, but the force required is con- 
siderable and it would seem that there might be danger of separating 
the epiphysis or otherwise injuring the joint, a danger that may be 
avoided by osteotomy. 

The adolescent type of genu valgum is not often extreme. As a rule, 



OPERATIVE TREATMENT. 423 

the deformity of the bone is of comparatively short duration, and it is 
accompanied by considerable laxity of ligaments. In the more chronic 
cases the osteotomy above the condyles may be performed in the 
manner described, but in Berlin and Vienna where the deformity is 
more common than in New York, other procedures are often employed. 

Wollf's Treatment. — One method* is that of Wollf, who by 
means of the " Etappen Yerband " gradually corrects the deformity. 

The patient is anaesthetized and the limb having been carefully pro- 
tected with cotton, particularly so about the malleoli, the patella and 
the inner condyle, is enveloped in a firm plaster bandage reaching from 
the malleoli to the pubes. When the plaster begins to harden one 
assistant steadies the pelvis, another holds the inner condyle, while the 
operator draws the leg inward with moderate but persistent force 
against the fulcrum formed by the hand of the second assistant and 
holds it firmly in the partly corrected position until the bandage is 
firm. About three days later a wedge-shaped section of the bandage 
about one inch in width is removed from the part that covers the inner 
half of the knee, the outer half of the bandage being simply divided. 
The leg is then forced inward until the two sections are again brought 
into contact. The position is retained by an additional plaster bandage 
about the weakened part. This procedure is repeated at intervals until 
the leg is completely straightened, a result that is often accomplished 
in two weeks. No anaesthetic is required for the secondary corrections. 
When the deformity has been corrected the patient is allowed to 
walk about, and for convenience the plaster bandage is divided into a 
thigh and leg part which are attached by lateral joints incorporated in 
its substance so that motion is allowed. This apparatus must be worn 
for several months and is of course to be supplemented by massage and 
exercises. 

Lorenz's Operation. — Another means of correction of deformity 
without open operation is that employed by Lorenz, what he calls " In- 
traarticulare modelirerende redressement." In this operation the de- 
formity is reduced under anaesthesia at one sitting by the gradual ap- 
plication of force by means of the Lorenz osteoclast. The reduction 
depends partly upon the stretching of the external ligaments and partly 
upon the actual bending of the diaphysis of the bone, as in the Wollf 
method. 

When the leg has been straightened, or somewhat over-corrected 
even, a long plaster bandage is applied which is worn for six weeks 
and is then replaced by a jointed walking brace to be worn for about 
a year. The operation is not attended by severe pain and the patient 
is usually allowed to walk about in a few days. 

Genu Varum. 

Synonym. — Bow Leg. 

The term bow legs includes, in its popular sense, all the distortions 
that cause a separation of the knees when the ankles are in contact with 
one another. But, strictly speaking, genu varum is the reverse of genu 



424 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



valgum, that is, the cause of the distortion is at or near the knee joint, 
while bow leg, as the name implies, is a simple bowing of the tibia and 
fibula, as a rule near the ankle joint. (Fig. 303.) In true genu varum a 
line dropped from the head of the femur falls inside the knee (Fig. 297), 
the inner condyle of the femur and the inner tuberosity of the tibia bear 
the greater part of the weight, the outer condyle is on the same level or 

somewhat lower than the 
Fig. 297. internal and the outer tuber- 

osity of the tibia may be 



Fig. 298. 







The genu varum type of bow legs, showing 
the outward rotation of the femora. 



The same patient, showing the separa- 
tion of the malleoli when the knees are in 
contact. 



somewhat higher than the internal. The femur is abducted and 
rotated outward, the tibia is rotated inward. These changes, it will be 
noted, are the reverse of those found in genu valgum. As has been 
stated, the deformity of genu valgum disappears when the legs are 
flexed, and in genu varum if the legs are flexed and the knees are 
placed in contact with one another the malleoli may be actually sepa- 
rated, simulating the deformity of knock knee. (Fig. 298.) This is 



SYMPTOMS. 425 

explained by the inward rotation of the femora, necessitated by placing 
the knees in contact with one another. 

*' In genu varum the distortion of the bones is not as strictly confined 
to the neighborhood of the knee joint as in genu valgum, and in simple 
bow leg there is almost always a certain amount of distortion at the 
knee, dependent, in part, upon laxity of the ligaments. It is proper 
therefore to use the two terms synonymously, although one must dis- 
tinguish a decided difference between the genu-varum type in which 
the deformity is greatest at the knee, and which is accompanied as a 
rule by marked laxity of the ligaments (Fig. 299), and the bow-leg 

Fig. 299. 



Genu varum of rhachitic origin in an adult. Treated successfully by osteotomy. 

type in which the deformity may be strictly confined to the lower third 
of the leg. (Fig. 303.) 

Symptoms. — As was said of genu valgum, the deformity is the 
principal symptom. The gait is somewhat rolling because each foot 
must describe a part of the arc of a circle before reaching the ground ; 
and because of the inward rotation of the tibiae or because of the in- 
ward spiral twist of the bone that is sometimes present, patients often 
toe in, in walking. 

Except in extreme cases the weakness and awkwardness, character- 
istic of genu valgum, are absent. This may be explained by the fact 



426 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



that the relation of the bones is such that the general attitude is one of 
activity, the weight falling on the outer side of the feet, thus flat foot 
is uncommon as an accompaniment of bow leg, except in the early or 
rhachitic type. 

Measurements. — The full effect of the deformity appears only when 
the weight of the body is borne, but for practical purposes the tracing 

of the extended legs is the best method 
Fig. 300. of recording the fixed deformity. In true 

genu varum the deformity is greatest at 
the knee and in the distortion the apposed 
surfaces of the femur and of the tibia 
participate. 

In simple bow leg the deformity may 
be confined to the tibia, which, in addition 
to the outward bowing, may be twisted 
inward somewhat upon its long axis. 

Genu varum may be unilateral or it 
may be combined with genu valgum of 
its fellow (Fig. 291), and occasionally 
slight knock knee and slight bow leg 
may be present in the same limb. 

Treatment. Expectant Treatment. — 
The slighter cases of bow leg in early 
childhood may be treated by manipula- 
tion. The leg, grasped firmly at the 
ankle and at the knee, is straightened 
with a certain amount of force, over and 
over again. Gradual correction by this 
means may be hastened by making the 
sole of the shoe slightly thicker on the 
outer border. This aids, also, in correct- 
ing the secondary pigeon toe, but if the 
foot is weak, as it usually is in rhachitic cases, this method should not 
be employed, as it might induce flat foot. 

Treatment by Braces. — If the deformity is more extreme, or if im- 
provement does not follow expectant treatment, apparatus should be 
employed. If the distortion is confined to the lower third of the tibia, 
a Knight brace may be used. It consists of two uprights attached to 
a foot plate, the inner bar is provided with a pad at its upper end for 
pressure on the internal condyle of the femur. The outer bar reaches 
to the head of the fibula and the two are joined by a calf band. When 
applied the leg is drawn toward the inner upright by means of a lacing, 
which passes about it within the outer bar. When the lacing is made 
fast, the outer bar is bent toward the leg and thus it aids somewhat in 
supporting it in an improved position. The foot plate may be dis- 
pensed with and the brace may be attached to the shoe and even the 
outer bar may be removed, leaving only the upright, which is held in 
position by the lacing. The apparatus, then, has the appearance of a 




Long braces for genu varum. (Brad- 
ford AND LOVETT. ) 



OPERATIVE TREATMENT. 427 

gaiter and has the advantage of being inconspicuous, although some- 
what less effective than the Knight brace. By this apparatus, combined 
with vigorous manipulation, the deformity may be corrected, in young 
children, in about six months. 

If the outward bowing of the knee is marked, another form of ap- 
paratus will be necessary, and its effectiveness will be much increased 
if there is no joint at the knee. The outer bar, shaped to the contour of 
the leg, is attached above to a pelvic band and below to a foot plate, as 
is the short brace. An inner straight bar extends to the upper third 
of the thigh and is attached to the outer bar by a thigh band. This 
inner upright is provided with a lacing of leather or canvas, similar to 
that of the short brace, which surrounds the knee and upper part of 
the leg, and thus draws it toward an improved position. The outer 
bar is then bent slightly inward and serves as an additional support. 
Another form of apparatus consists of a single upright, attached to the 
shoe and extending upward as high as possible on the inner aspect of 
the thigh. At its upper extremity a pressure pad is placed and the 
knee is drawn toward it by means of straps or bandages. 

An improved brace of this kind is that in use at the Boston Children's 
Hospital, in which the upper part of the upright is curved upward and 
outward just below the groin, to a point on a level with, and behind, 
the trochanter, and is attached to its fellow by means of a strap passing 
across the buttocks so that the feet may be somewhat rotated outward 
if necessary. (Fig. 300.) 

Operative Treatment. — In children more than five years of age, and 
in cases of the more extreme type at an earlier age, or when the op- 
portunity for mechanical treatment is lacking, immediate correction 
of the deformity is indicated. Either osteoclasis or osteotomy may be 
employed, and in some instances manual force is sufficient for the 
correction of the deformity. There is but little choice between the 
methods. Osteoclasis is somewhat safer possibly, and is to be pre- 
ferred for the younger patients who may be treated as out-patients. 

At the Hospital for Ruptured and Crippled, osteotomy is almost 
invariably performed. The small osteotome is inserted on the inner 
aspect of the tibia at the point of greatest deformity, and when the 
bone has been sufficiently weakened, the fracture is completed by 
manual force. The fibula may be broken at the same time, or, as is 
usually the case, it may be simply bent outward. The deformity is 
corrected or slightly over-corrected and a well-fitting plaster bandage, 
including the foot and extending to the trochanter, is applied. 

The patient usually remains in bed for a few days, he is then dressed 
and if he so desires is allowed to stand. Almost no pain or discom- 
fort follows the operation and in fact, in properly selected cases, it is 
not only free from danger, but it has a very decided advantage over 
the simple mechanical treatment. If the child is in good condition, 
and if the deformity is slightly over-corrected at the time of operation, 
apparatus will not be required in the after-treatment ; but in many 
instances some form of support is indicated, usually because slight 



428 



DEFORMITIES OF BONES OF LOWER EXTREMITY. 



deformity, due to laxity of ligaments or to deformity of the femur, 
appears when the weight of the body falls upon the legs. 

It^has been stated that the deformity of bow leg depends in part 

upon a deformity of the femur as 
Fig. 301. we ll as of the tibia. As a rule, 

**-—^*^gtt~ the correction of the greater de- 

H^9jj£ formity of the tibia will be suffi- 

cient, but in more extreme cases a 
secondary osteotomy above the 
condyles will be necessary. This 
may be performed simultaneously 
with that on the tibia, but it is 
better to defer it until the effect 
of the primary operation has been 
observed. 



Anterior Bow Leg*. 

Synonym. — Anterior Curva- 
ture of the Tibia. 
Anterior bow legs. Both bow legs and knock knees 

are often seen in children who pre- 
sent no signs of general rhachitis, but anterior bowing of the legs is 
almost always combined with general rhachitic distortions of the lower 
extremity, most often with knock knees ; these in turn are caused by 
marked distortion of the femora which may be bent forward and out- 




Fig. 302. 




Long anterior curvature of the tibia and flat foot. 



GENERAL RHACHITIC DISTORTIONS. 



429 



ward above, and inward at their lower extremities, " corkscrew de- 
formity." In anterior bow legs the tibise are usually flattened from 
side to side, curved inward or outward and bent forward, the project- 
ing crests presenting sharply beneath the skin. 

Symptoms. — The effect of the anterior bowing is to throw the weight 
forward upon the foot, thus the heels appear abnormally long and promi- 
nent, and the patient 

seems to sink forward at Fig. 303. 

each step. (Fig. 303.) 
The knees are usually 
somewhat flexed, partly 
as the effect of knock 
knee with which the de- 
formity is usually com- 
bined, and the feet are, 
as a rule, flat. As has 
been stated, anterior bow- 
ing is almost never seen 
as an independent defor- 
mity unless it is a relic of 
the more general distor- 
tion which has been 
" outgrown." 

Treatment. — Anterior 
curvature of the tibia 
must, as a rule, be 
treated by operation. 
After complete division 
of the tibia and fibula, 
the deformity may be 
overcome by forcing the 
bones directly backward. 
In certain instances te- 
notomy of the tendo 
Achillis may be required. 
Cuneiform osteotomy of 
the tibia permits more 

perfect correction, but the final result is equally good after simple 
osteotomy. 

General Rhachitic Distortions. 

General rhachitic distortions have been mentioned in connection with 
knock knee, and with anterior bow leg. A more extended description 
is hardly necessary. The deformities are usually of the knock-knee 
type, and they may be treated on the same general plan that has been 
outlined in the description of the less extreme distortions. 




Khachitic anterior buw legs. 



CHAPTER XVI. 
DEFORMITIES OF THE UPPER EXTREMITY. 

Congenital Dislocation of the Shoulder. 

This may occur in two forms, one in which there is actual mis- 
placement before birth, and the other in which a dislocation is caused 
by violence at birth. In either case the displacement is almost always 
backward upon the dorsum of the scapula (subspinous). Thus the 
arm is abducted and rotated inward and the head of the displaced 
bone may be felt in its abnormal position. Cases of congenital dis- 
placement in other directions are recorded, but these are so unusual 
as to be of little practical importance. 1 

True primary displacement of either variety is rare. Many of the 
reported cases were apparently subluxations secondary to the relaxa- 
tion of the capsule of the joint and to the muscular atrophy caused by 
anterior poliomyelitis, or more often to the habitual malposition due 
to obstetrical paralysis. (Fig. 305.) 

Treatment. — The only treatment of a dislocation is replacement of 
the displaced bone, if it be possible. If the displacement were dis- 
covered in infancy, it might be possible to reduce it by manipulation, 
especially if it were of traumatic origin. As a rule, however, the 
cases are not seen until later childhood when the accommodative 
changes are so great as to necessitate the open operation. 

Phelps, of New York, has reported several cases of congenital 
dislocation of the shoulder, caused apparently by injury at birth, as 
most of them were accompanied by paralysis. In the first case (a 
boy eight years of age) the joint was opened by a posterior incision 
along the border of the deltoid muscle. The head of the scapula was 
found to be atrophied and the posterior margin of the glenoid cavity 
broken away. This, together with the contraction of the tissues on 
the anterior aspect of the joint, made it necessary to cut away a part 
of the head of the bone in order to replace it. The secondary 
articulating surface on the scapula was excised and the redundant 
capsule was removed. The immediate result of the operation was 
very favorable. Phelps states that he has operated on two similar 
cases, but a final report of the results has not been presented. 2 

It would seem, however, that as in a posterior displacement the con- 
tracted tissues must be those in front of the joint, an anterior rather 
than a posterior incision, would be preferable. In any event prolonged 

1 Scudder, Am. Jour. Med. Sci., February, 1898. 

2 Trans. Am. Orth. Ass'n, Vol. VIII. 



OBSTETRICAL PARALYSIS. 



431 



Fig. 304. 



forcible manual stretching of the contracted parts in the manner de- 
scribed in the treatment of congenital dislocation of the hip should 
precede the opening of the joint. By this means the writer has re- 
duced the displacement easily in two cases in early childhood. 

Obstetrical Paralysis. 

Partial or complete paralysis of the muscles of the arm may be a re- 
sult of difficult or protracted labor. This may be due to direct injury 
of the brachial plexus by the forceps, but most often it is caused by 
traction on the body or the head 
and by violent twists of the neck 
during delivery. The muscles most 
often paralyzed are those supplied 
principally by the fifth and sixth cer- 
vical roots of the plexus, the deltoid, 
the biceps, and the supinators of the 
forearm. 1 Thus in most instances 
the arm hangs in an attitude of slight 
abduction and exaggerated prona- 
tion. (Fig. 304.) If the attitude 
is allowed to persist and if the 
paralysis is permanent, the head 
of the humerus rotated backward 
beneath the atrophied deltoid mus- 
cle and held in the abnormal atti- 
tude by accommodative changes in 
the capsule and surrounding parts, 
simulates very closely in later years 
the true congenital dislocation of the 
shoulder. (Fig. 305.) 

Whether cases reported as con- 
genital displacement of the shoulder 
are secondary to paralysis or not, it 
is evident that all cases of obstet- 
rical paralysis should be carefully 
examined with regard to a compli- 
cating dislocation, and that secondary deformity caused by paralysis 
should be prevented. 

Treatment. — During the first month after birth, the shoulder of 
the paralyzed arm is often somewhat swollen and motion may cause 
pain. In such cases rest is indicated. The arm should be placed 
against the side, and the hand, with the fingers extended, should be 
supported on the chest beneath the clothing. When the primary sen- 
sitiveness has subsided, each of the joints of the extremity should 
be moved systematically to the limits of the normal range of motion 
several times in the day. Particular care should be exercised in 
supinating the forearm to its full limit and extending the wrist and 

1 Thomas, Johns Hopkins Hosp. Bulletin, Nov., 1900. 




Obstetrical paralysis. Characteristic attitude. 



432 



DEFORMITIES OF THE UPPER EXTREMITY. 



fingers, if they are involved in the paralysis. The muscles should be 
massaged and the arm should be supported by a sling, or otherwise, 
in proper position. Recovery may be complete, although it is often 
delayed for many months. As a rule, traces of the injury are evident 
in atrophy of certain muscles, particularly of the deltoid, and a certain 
weakness of the arm persists, even though no paralysis remains. 

In many instances recovery is but partial, the arm is weak, certain 
muscles are paralyzed, and there is much restriction of movement at 

the shoulder. The growth of 
Fig. 305. the member is retarded and the 

attitude simulates that of pos- 
terior dislocation, as has been 
stated. Even in such cases 
massage and exercises and 
training will often improve 
the functional ability of the 
disabled part. 

Recurrent Dislocation of 
the Shoulder. 

Recurrent dislocation of the 
shoulder is usually a sequel to 
traumatic dislocation. The 
cause of the instability is usu- 
ally laxity of the capsular lig- 
ament and weakness of the 
supporting muscles, the result, 
it may be, of too early use of 
the arm after the accident. 
In rare instances greater de- 
rangement of the joint, caused 
by fracture of one or other of 
the articulating surfaces, rup- 
ture or displacement of liga- 
ments or muscles, or perma- 
nent paralysis of the deltoid 
muscle may be present. 

The displacement, which 
may be partial or complete, recurs at intervals and is a very serious 
disability. 

Treatment. — If the patient is seen immediately after a displacement 
and if the dislocation has recurred but a few times and at long inter- 
vals, it may be inferred that the disability is the result of simple laxity 
of the capsule and of muscular weakness. In such cases a period of 
fixation followed by massage and exercise of the atrophied muscles may 
result in cure. The patient should be carefully questioned as to the par- 
ticular movements of the arm that are likely to cause the displacement, 




Obstetrical paralysis in adolescence. 



CUBITUS VALGUS, CUBITUS VARUS. 433 

which is, as a rule, forward beneath the coracoid process. Most often 
elevation and abduction seem to be the exciting causes, and these mo- 
tions should be restrained. A simple and often an effective means of 
treatment, is the application of a shoulder cap of canvas that fits closely 
about the shoulder and upper arm. This is held in place by bands 
crossing the body and buckled beneath the other arm ; from the lower 
border of the cap one or more bands pass downward and are attached 
with the braces to the trousers, so that elevation of the arm is re- 
strained, before the point of instability is reached. 

Operative Treatment. — If these milder measures are ineffective an op- 
eration to reduce the size of the lax capsule may be performed according 
to the method employed by Burrell. The arm being slightly abducted, 
an incision is made from the coracoid process downward and outward 
along the line of the cephalic vein to a point below the upper border of 
the tendinous insertion of the pectoralis major. The deltoid and the 
pectoralis major are separated, exposing in the upper border of the 
wound the coraco-brachialis, and in the lower angle the upper part of the 
insertion of the pectoralis major. The upper three- fourths of this in- 
sertion is divided in order to expose the head and neck of the bone. 
The humerus is then rotated outward and a portion of the insertion of 
the subscapulars muscle, stretched over the head of the humerus, is di- 
vided. The capsule is thus laid bare. 

In Burrell' s second case a portion of the anterior wall of the capsule 
three-eighths of an inch wide and three-fourths of an inch long was 
excised, and the wound was closed with sutures. The incised muscles 
fell into apposition when the arm was fixed to the side. Burrell oper- 
ated on two patients by this method with perfect success. 

Similar operations in which the lax capsule was overlapped and 
sutured without opening it, have been performed, by Ricard in 1892 
and by Steinthal in 1895. 1 

Congenital Deformities of the Elbow. 

Congenital displacement of the ulna is one of the rarest of deform- 
ities. The displacement is usually incomplete, and it is associated with 
laxity of the ligaments. 

Congenital displacement of the radius is much more common. 
Thirty cases collected from the literature have been reported by Bon- 
nenburg. 2 The symptoms are similar to those of the traumatic dislo- 
cation. The deformity is often overlooked in childhood, and as it 
causes no great disability, treatment is not usually desired. In several 
instances the head of the radius has been removed with a favorable ef- 
fect in increasing the range of supination. 

Cubitus Valgus, Cubitus Varus. 

Cubitus valgus, in which the forearm is abducted at the elbow and cu- 
bitus varus, in which it is inclined in the other direction, are occasion- 

1 Burrell and Lovett, Am. Jour. Med. Sci., Aug., 1897. 

__ 2 Zeits. fur Orth. Chir.. Bd. 2. 

2io 



434 DEFORMITIES OF THE UPPER EXTREMITY. 

ally seen as congenital deformities. They are, in most instances, asso- 
ciated with laxity of the ligaments. 

Similar deformities are not uncommon during the progessive stage of 
rhachitis, but they usually disappear when the erect attitude is assumed 
and when the arms are relieved of the strain of supporting the body in 
the sitting posture. What may be called normal cubitus valgus, is 
common among women, and in certain instances it may be exaggerated 
to deformity. Acquired cubitus varus is usually the result of direct 
injury. 

Subluxation of the Wrist. 

A peculiar displacement of the hand forward and to the radial or 
ulnar side, described by Madelung * as " spontaneous subluxation," is 
sometimes seen in young subjects whose occupation may require con- 
stant use of the flexors of the hand and fingers. In these cases the 
lower extremities of the bones of the arm project on the dorsal surface, 
the flexor tendons are prominent on the palmar aspect and limit the 
range of extension of the hand, the wrist may be slightly enlarged and 
the ligaments seem to be relaxed. The symptoms, aside from the de- 
formity, are weakness and sensations of discomfort about the dorsum 
of the wrist. 

Etiology. — The predisposing causes of the affection are, apparently, 
relaxation of the ligaments and, possibly, slight preexisting rhachitic 
deformity of the same character. The exciting causes are occupation 
or injury. In some instances there is a slight forward bending of the 
lower extremity of the radius, due, apparently, to irregularity in growth 
at the epiphyseal junction. 

Treatment. — The treatment is rest, massage, forcible manipulation 
in the direction of extension and a support of leather or other material 
to hold the hand in the extended position until the tendency to defor- 
mity is checked. 

Congenital Deformities at the Wrist. 

Simple congenital dislocation of the wrist is extremely rare. Dis- 
placement of the wrist and hand is usually associated with defective 
development of the bones of the arm, and the deformity is usually 
classed as club hand. 

Club Hand. 

Congenital distortions of the hand may be divided into four primary 
varieties, according to the direction in which the hand is turned, viz.: 

1. Forward or palmar. 

2. Backward or dorsal. 

3. Lateral to the radial side — radial. 

4. Lateral to the ulnar side — ulnar. 

Lateral and antero-posterior distortions occur also in combination. 
Etiology.— There are two distinct varieties of club hand : 

iArchivf. Klin. Chir., Bd. 23. 



CLUB HAND. 



435 



1. In which there is simple distortion caused apparently by ab- 
normal fixation and pressure in utero. 

2. In which the deformity is associated with defective develop- 
ment of the radius or ulna and often with congenital abnormalities of 
other parts. 

In the palmar and dorsal distortions the bones of the arm are usually 
normal. The lateral deviations of the hand are often caused by de- 
fective formation of the radius or ulna, and thus they correspond to 
talipes due to absence of the tibia or fibula. 

According to Hoffa, 1 39 cases of the former and but 6 of the latter 



are recorded ; in but one case 



was 



there entire absence of the ulna. 



Fig. 306. 




Club hands and club feet. 



Of the 39 cases of radial club hand 19 were of both sides. These sta- 
tistics, however, by no means represent the relative frequency of the 
deformity. From the writer's observation it would appear that radial 
club hand is nearly as common as the deformity of the foot caused by 
absence of the fibula, of which, according to Potel, there are 200 re- 
corded cases. The ulnar form of club hand is less frequent even than 
the deformity due to defective formation of the tibia. 

The most important form of club hand is, then, that due to absence 
or to defective formation of the radius. As in talipes valgus due to 
absence of the fibula, the tibia is short and often bent sharply forward, 
so in this form of club hand the ulna is usually short and bent inward. 
The hand may be perfect in formation, but as a rule the thumb is ab- 

1 Lehrb. der Orth. Chir., p. 481. 



436 



DEFORMITIES OF THE UPPER EXTREMITY. 



sent or rudimentary and other adjoining bones, together with the cor- 
responding ligaments and muscles, may be absent also. (Fig. 307.) 

The hand occupies practically a right-angled relation to the ulna 
and as this bone is usually bent inward as well, the direction of the 
hand is often reversed and is parallel to the forearm. As a rule the 
hand is also somewhat bent forward, so that the deformity might be 
described as radio-palmar. (Fig. 308.) 

Treatment. — In those forms of club hand in which the structure 
is normal the deformity may be overcome as a rule by manipulation, 
and support by the plaster bandage or otherwise. Massage and mus- 
cle training are required in the after-treatment. 

In slighter cases of radial club hand, due to defective development, 

Fig. 307. 




Congenital absence of radius and the bones of the thumb. (Weigel.) 

it may be possible by manipulation and tenotomy to replace the hand 
in its normal position, but this is unlikely. As a rule an operation on 
the ulna will be necessary, together with division of the. contracted 
tissues. Sayre * removed a portion of the carpus and implanted the 
head of the ulna at the point of resection. McCurdy 2 sawed through 
the ulna, leaving the extremity in relation to the carpus and sutured 
the proximal fragment and the semi-lunar bone to one another. 
Thomson 3 replaced the hand by subcutaneous tenotomy and by the re- 
moval of a cuneiform section of bone from the lower end of the ulna. 
The operation of splitting the ulna into an ulnar and radial portion 



'Trans. Amer. Orth. Ass'n, Vol. 
2 Ibid., Vol. VIII. 
3 Ibid., Vol. IX. 



VI. 



WEBBED FINGERS. 



437 



and implanting the carpus between the two, has been performed by 
Bardenhauer. 1 The immediate effect of the various operative proce- 
dures was favorable, but no final results have been reported. 

In any event some form of apparatus must be used during child- 
hood at least, to support the hand, whether the operation has been 
successful or not ; and at best the arm 
will be short, and the thum bless hand -pm. 308. 

will be weak as compared with the 
normal. 

Congenital Contraction of the 
Fingers. 

The most common form of congenital 
contraction is that of the little finger, on 
one or both hands, which is semi-flexed, 
apparently, because of deficiency of the 
skin. In other instances several fiDgers 
may be similarly affected. 

Treatment. — If treatment by manip- 
ulation and splinting is begun early the 
deformity may be overcome by length- 
ening the contracted tissues. In later 
life the prospect of perfect cure by any 
method of treatment is slight, because 
of the strong tendency to recontraction 
after the finger has been straightened. 

Webbed Fingers. 

In the most common form of this de- 
formity two or more fingers are joined by 
skin and fibrous tissue to the first pha- 
langeal joints, but sometimes through- 
out the entire length of the fingers. 

In other instances the web may be 
thicker, containing muscular fibers from 
the apposed parts and, occasionally, the 
bones of the two fingers may be joined to 
one another, even to the finger nails. 

Etiology. — The cause of the deformity is arrest of development before 

the fingers have been separated from one another, thus the thumb, which 

is differentiated from the other parts of the hand as early as the 

seventy-fifth day of intra-uterine life, is rarely involved, as compared 

. with the fingers which are separated from one another at a later period. 

Treatment. — In all but the extreme grades of deformity the fingers 
may be separated from one another ; operative treatment being con- 
ducted according to the rules of plastic surgery. 

1 Verhand. der deutsch. Gesells. fur Chir., 23 Kong., 1894. 




Congenital club hands, showing 
the short and deformed forearms, also 
bow legs. (Gibney.) 



438 DEFORMITIES OF THE UPPER EXTREMITY. 

Congenital Displacements of the Phalanges and Distortions 

of the Fingers. 

These deformities are not particularly uncommon. They should be 
treated by manipulation and by splinting at as early a period as is 
practicable. Other congenital deformities and malformations of the 
hand do not call for extended comment. 

Trigger Finger. 

Synonyms. — Jerking Finger, Snapping Finger. 

This affection was first described by Nelaton under the title Doigt a 
Ressort. On extending the closed hand one finger remains flexed. If 
the flexion is overcome by greater muscular effort or by passive force 
the finger flies back to complete extension with a sudden snap or jerk, 
hence the name. In well-marked cases the same difficulty and the 
subsequent snap is experienced in flexing the finger. The middle and 
ring fingers are more often affected but sometimes the thumb or the 
fifth finger may be involved. 

The patient usually complains somewhat of stiffness and pain in the 
finger but the interference with its function is the principal symptom. 

Etiology. — The usual explanation of the disability is interference 
with the motion of the tendon in its fibrous sheath, either because of a 
reduction of its calibre due to injury or inflammation, or to an enlarge- 
ment or irregularity of the tendon itself. In most instances the obstruc- 
tion appears to be in the neighborhood of the metatarso-phalangeal joint. 

The duration of the affection is indefinite. 

Treatment. — If the obstruction appears to be of inflammatory or 
traumatic origin it may be treated by splinting and later by massage. 
In confirmed cases the tendon and the sheath may be explored in the 
hope of finding and removing the obstruction. 1 

Mallet Finger. 

Synonym. — Drop Finger. 

This is caused usually by a blow upon the terminal phalanx which 
ruptures or weakens the attachment of the extensor tendon at the base of 
the phalanx so that it is habitually flexed to a right angle with the finger. 

The treatment must be by incision and reattachment of the tendon 
to the periosteum. 

Baseball finger (Abbe) is the reverse displacement of the terminal 
phalanx which is dislocated backward, forming a bayonet-like deformity. 

If reposition is impossible open incision should be employed to cor- 
rect the deformity. 

Dupuytren's Contraction. 

Dupuytren's contraction is a deformity of the hand caused by contrac- 
tion of a part of the palmar fascia and of its prolongations to one or 

1 The bibliography is large. More recent articles are those of Jamin, Cent, fur Chir., 
June 6, 1896, who reports 31 cases and A. Necker, Beitrage zur Klin. Chir., Bd. X., 
p. 469. 



DUPUYTBEN'S CONTRACTION. 439 

more of the fingers. The fingers are flexed as a consequence, to a 
greater or less degree, and in advanced cases they may be drawn to close 
contact with the palm. The ring finger is most often primarily affected 
but as a rule two or more fingers are somewhat involved in the contraction. 

In a large proportion of the cases both hands are involved, but not 
as a rule simultaneously, the contraction beginning in the second hand 
several years after the deformity in the first. 

Pathology. — The characteristics of the deformity are explained by 
the anatomy of the palmar fascia. This consists of a strong central 
portion, and two thinner lateral parts that cover the muscles of the 
thumb and little finger. It is made up of longitudinal fibers continu- 
ous with the tendon of the palmaris longus and the annular ligament. 
It divides into four processes that are attached to the digital sheaths, to 
the integument at the clefts of the fingers and to the superficial trans- 
verse ligament. Prolongations of the fascia pass along the lateral 
aspect of the fingers and are attached to the periosteum and to the 
tendon sheaths of the first and second phalanges. 

The cause of the contraction appears to be a chronic plastic inflam- 
mation of a part of the fascia, which becomes hypertrophied, and finally 
contracts, drawing the finger toward the palm in the manner described. 

Etiology. — The etiology is uncertain. 

The contraction is much more common in men than in women and 
it is practically confined to middle and later life. It is claimed that 
the deformity is more common among those who are subject to gout or 
rheumatism. It appears also to be an hereditary affection in certain 
instances. Injury or irritation of the palmar tissues, incident to cer- 
tain occupations, would seem to explain the disproportionate liability 
of the sexes to the affection. 

Symptoms. — The first symptom is usually the deformity ; the pa- 
tient finds it impossible to completely extend one or more of the 
fingers, the tissues about the base of the finger seem stiff, and when it 
is forcibly extended a hard, elevated cord may be felt extending from 
about the center of the palm to the second phalanx, most prominent 
at the metacarpophalangeal articulation. 

To this the skin is adherent, and as the contraction increases it is 
thrown into elevated ridges. Later, other bands appear if the con- 
traction affects, as it usually does, other portions of the fascia. In 
many instances no pain is experienced unless the contracted fascia is 
forcibly stretched or is pressed upon. In other cases complaint is 
made of neuralgic pain in the hand and even in the arm and back. 
Occasionally the first symptom to attract attention may be a sensitive 
nodule in the skin at the base of the finger. 

The contraction usually increases slowly until the finger that is most 
affected is drawn to the palm. 

Treatment. — The deformity maybe overcome by division or prefer- 
ably by removal of the contracted bands of fascia. The finger is then 
supported in an attitude of slight flexion until the circulation is adjusted 
to the new position. 



CHAPTER XVII. 
DISEASES OF THE NEEVOUS SYSTEM. 

Fkom the orthopaedic standpoint, only those diseases that directly in- 
terfere with the function of locomotion or that cause deformity, and 
for which local treatment is of benefit, are of especial interest. Even 
this limited class is not often seen in the early or progressive stage 
and it is rather with the effects of a disease that is no longer present 
than with the disease itself that the orthopaedic surgeon is especially 
concerned. 

The relative importance of this branch of orthopaedic work may be 
illustrated by the statistics of the Hospital for Ruptured and Crippled. 
In a period of ten years, 1890-1899, forty- two thousand one hundred 
and twenty-four new patients were examined in the out-patient de- 
partment. Excluding cases that cannot properly be classed as ortho- 
paedic, thirty-eight thousand four hundred and nineteen remain. In 
two thousand four hundred and forty-one of these the nervous system 
was involved (6.3 per cent.). Two thousand and twenty-eight of the 
cases were in young children ; four hundred and thirteen of the pa- 
tients were more than fourteen years of age and of this number two 
hundred and sixty-six were adults. 

Anterior poliomyelitis furnished about 75 per cent, of the total 
number. In 20 per cent, the cerebrum was involved and 5 per cent, 
were miscellaneous cases. In 611 cases treated in a period of about 
two years there were 463 cases of poliomyelitis, 121 cases of paralysis 
of cerebral origin, 16 cases of obstetrical paralysis, 4 cases of pseudo- 
hypertrophic muscular paralysis and 7 miscellaneous cases. 

These statistics will explain the selection of diseases of the nervous 
system for consideration and the order in which they are described. 

Acute Anterior Poliomyelitis. 

Synonym. — Infantile Paralysis. 

Pathology. — Anterior poliomyelitis is an acute inflammatory process 
of the area of the gray matter of the anterior cornua supplied by the 
anterior spinal arteries involving both the neuroglia and the cells, and 
resulting in degeneration and atrophy of the interstitial tissue and of 
the ganglion cells. 1 

In the acute febrile form, comprising about three-fourths of the 
cases, there is an actual inflammation ; in the other type, in which there 
are no constitutional evidences of disease, the symptoms may be caused 
by hemorrhage or by thrombosis. 

1 Starr, Loo mis-Thompson, System of Practical Medicine. 



ETIOLOGY. 



441 



The minute changes in the cord are characteristic of inflammation, 
distended blood vessels, minute hemorrhages, infiltrating leucocytes 
and serum. In the early stage the motor cells become cloudy in ap- 
pearance, later they are swollen and lose their distinct outlines. The 
degenerative changes affect both the cells and neuroglia ; the affected 
gray matter shrinks and the nerve fibers atrophy, and the cord becomes 
distinctly smaller at the seat of the disease. When the motor con- 
ductivity of the cells is cut off, the muscles which are supplied by them 
are paralyzed and waste away. The circulation in the affected parts 
is impaired, contractions and distortions appear and growth is retarded. 

Etiology. — The etiology of the disease is obscure. Exposure to 
heat, sudden chilling of the body, over-fatigue, injury and the like, are 
thought to be predisposing causes, while the direct cause of the inflam- 
matory disease of the cord is supposed to be some form of infection. 

The disease affects the sexes in nearly equal numbers, and those in 
perfect health as often as those whose resistance is enfeebled. It some- 
times occurs in epidemics and there are instances in which several 
members of the same family have been affected, but usually the cases 
are isolated and no adequate cause for the disease can be assigned. 

Age. — Acute anterior poliomyelitis is essentially a disease of infancy. 
This is illustrated by the combined statistics of several observers tabu- 
lated by Starr. 1 



Seeligmuller , 
Galbraith .... 

Sinkler 

Gowers 

Starr 



. 




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u 








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c3 


OS 


ci 


a 


cS 








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V 


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03 


<o 


<v 


43 




>. 






>> 


>. 


>. 


>> 


►» 


>» 




.£ 






A 


A 


A 


A 


A 


A 


A 
























*. 


M> 


T}< 


lO 


to 


t^ 


CO 


OJ 




20 


25 


18 


1 


1 


2 








o 





17 


38 


15 


4 


1 

















44 


92 


55 


29 


9 


2 


3 


6 





3 


21 


21 


25 


9 


17 


4 


2 


6 


4 





16 


38 


27 


9 


10 


4 


2 


2 


4 


3 


118 

> 


214 


140 


52 


38 


12 


7 


14 


> 8 


6 



472, or 77 per cent., before the fourth year. 



It is far more common during the warm months than at other sea- 
sons, as is illustrated in 452 cases tabulated by Starr. 2 

January 8 

February 5 

March 20 

April 9 

May 18 

June 49 "j 

July 97 

August 116 

September 65 

October 42 

November 11 

December 12 

452 



327, or 72 per cent., during the four 
months, June to September. 



1 Loomis-Thompson, System of Practical Medicine. 



2 Loc. cit. 



442 



DISEASES OF THE NERVOUS SYSTEM. 



Distribution of the Paralysis. — The lower extremities are far more 
often paralyzed than the upper. In 416 of 595 cases, tabulated by 
Starr, the paralysis was limited to the lower extremities, as contrasted 
with 53 cases in which the upper extremities were alone involved. 





a 

a 


.2 

C0 . 


£ 

s 

a 
33 


u 
03 


3 

o 
H 


Both legs 


9 
25 
7 
5 
5 
2 
5 

I 

1 



14 
15 
27 
9 
4 
1 
2 

t 





107 
63 

62 
5 

8 
1 
35 
26 
1 
22 
10 


40 
20 
27 
7 
4 
2 
5 
4 
4 
3 
2 


170 


Right leer 


123 


Left leg 


123 


Right arm 


26 


Left arm 


21 


Both arms 


6 


All extremities 

Arm and leg same side 

Arm and leg opposite sides 

Trunk 


47 

33 

8 

26 


Three extremities 


12 




62 


75 


340 


118 


595 



Symptoms. — The disease is usually divided into several stages : 

1. The stage of onset. This is usually attended by constitutional 
symptoms, by fever and headache, even by convulsions and delirium ; 
by vomiting and intestinal disturbance, or occasionally by severe pain. 
In most instances the elevation of the temperature is not extreme, nor 
is the constitutional disturbance severe, and but for the paralysis, the 
attack would be considered as one of the ordinary illnesses so common 
in childhood. In some cases however the fever is high and there may 
be convulsions and prolonged unconsciousness, while in others there 
may be no premonitory symptoms whatever, the child is apparently 
well at night, but wakens in the morning paralyzed. 

In many instances the weakness caused by anterior poliomyelitis is 
not discovered until the child begins to walk, when the awkward gait, 
or limp, or the distortion of a foot, may make it evident. 

In a few hours, or a few days, after the first symptoms of the dis- 
ease the paralysis appears ; its area may extend slowly after it is recog- 
nized or its extreme limit may be reached at once. This original 
paralysis is always greater than that which finally persists. The dura- 
tion of the first stage may be from a few hours to a week. 

2. Then follows a stationary period, lasting from a week to a 
month ; the constitutional symptoms cease, but the paralysis remains. 

3. This is succeeded by the stage of partial recovery, lasting from 
one to six months or longer. The muscles which were paralyzed be- 
cause of the secondary congestion and exudation about the local mye- 
litis, recover their power in whole or in part, while those muscles sup- 
plied from the area in the cord in which the nerve cells have been 
destroyed, waste away. At this time the contractions and distortions 
in the paralyzed part appear. 

4. The chronic stage. This may be considered to last until adult 



^ 



DIAGNOSIS. 443 

age, or until the ultimate damage to the individual, due to the retarda- 
tion of the growth and unbalancing of the mechanical equilibrium of 
the body, may be summed up. 

The sensation of the paralyzed part is not affected except in the ex- 
treme cases. The temperature is lower from the first. In many in- 
stances the limb is not only cold, but it is congested and blue. These 
circulatory disturbances are caused primarily by the interference with 
the vaso-motor system, but they are confirmed later by the atrophy of 
the muscles and by the permanent contraction of the blood vessels. 
Thus, in general, the impairment of the circulation corresponds to the 
degree of the paralysis, but not absolutely so. In certain cases the 
paralysis may be very limited in extent, and yet the limb may be cold 
and congested, while in others in which the loss of power is much 
greater the temperature is but slightly lowered and the color remains 
normal. The same is true of retardation of growth. In most in- 
stances the ultimate shortening of the limb corresponds to the degree 
of the paralysis, and consequent loss of function ; but occasionally cases 
are seen in which the growth is markedly retarded although but few of 
the muscles are paralyzed. 

Diagnosis. — It is doubtful if the diagnosis of acute anterior polio- 
myelitis could be made before the stage of paralysis. But after the 
paralysis has appeared there should be little difficulty in interpreting 
the symptoms. It is a disease usually of acute onset, followed by 
paralysis of certain muscular groups or of entire members. It is a 
flaccid paralysis, the reflexes are lost, the muscles no longer contract 
under faradism and the reaction of degeneration is present ; the tissues 
waste and the circulation is impaired in the affected parts. 

It is usual to consider, first, in differential diagnosis the paralyses 
of cerebral origin, but this is more for the purpose of calling attention 
to the essential differences between the two, than because they are 
likely to be confounded by one acquainted with the ordinary charac- 
teristics of cerebral and spinal disease. 

Paralysis of Cerebral Origin in Childhood. — In paralysis of cerebral 
origin, the common form is hemiplegia. It usually follows convul- 
sions and the intelligence may be impaired. The paralysis is not com- 
plete, nor is it limited to groups of muscles ; it is rather powerlessness 
or impairment of function, due to loss of cerebral control. The reflexes 
are increased and limbs are stiffened, not flaccid. The electrical reac- 
tions are not lost or changed in quality. Paralysis of cerebral origin 
may be also paraplegic or diplegic in its distribution, but in these cases 
the general characteristics are the same as in the hemiplegic form, ex- 
cept that the intelligence is more markedly affected. 

Other Forms of Spinal Paralysis. — Transverse myelitis is very un- 
common in childhood. In this disease the distribution is equal, the re- 
flexes are at first increased and sensation as well as motion is lost. 

Pott's Paraplegia. — In this form of paralysis, also, the distribution is 
equal, the reflexes are increased and the signs of the disease of the spine 
are always present. 



444 DISEASES OF THE NERVOUS SYSTEM. 

Rheumatism and Joint Disease. — In orthopaedic practice, anterior 
poliomyelitis is not often seen in the early stage, unless pain is a 
prominent symptom, when the disease may be mistaken for rheuma- 
tism or for some form of joint disease. Cases of this type are not un- 
common. The muscles are sensitive to pressure and the movements 
of the joints cause discomfort. In certain instances the paralysis may 
not be apparent on the first examination ; Avhen it does appear the di- 
agnosis is, of course, established, therefore the characteristics of disease 
of the joints need not be detailed. 

Multiple Neuritis. — Multiple neuritis is usually a sequel of infectious 
disease, or of metallic poisoning. In the cases due to metallic poison- 
ing with lead or arsenic, the paralysis usually begins in the extensors 
of the hands and feet, and is symmetrical in its distribution. This is 
true also of the limited forms of paralysis following contagious diseases 
in which the dorsal flexors of the feet are most often involved. In 
multiple neuritis there is usually local sensitiveness lasting a longer 
time than in poliomyelitis, and the paralysis is gradual in its onset and 
the sensation, as well as motion, is affected. 

Diphtheritic Paralysis. — Diphtheria is the most common cause of 
general weakness terminating in paralysis, but in these cases there is 
usually a history of the preceding disease. The paralysis appears first 
in the muscles of the throat and neck, and a general and increasing 
weakness precedes for a considerable interval the complete loss of 
power. 

Weakness. Pseudo-Paralysis. — Weakness caused by rhachitis, or 
so-called pseudo-paralysis, due to this or to other affections, is readily 
distinguished from actual paralysis by pricking the part with a pin 
when the muscular contraction will be evident. This test of function 
is of value in shoAving the distribution of the paralysis. Loss of power 
in the tibialis anticus muscle, for example, causes valgus resembling 
closely the ordinary valgus due to simple weakness. In simple weak- 
ness the child withdraws the foot from the point of the pin, and the 
ability to move it in all directions is very evident ; but if the tibialis 
anticus muscle is paralyzed, the foot is always flexed in the abducted 
attitude. The same test may be made for paralysis of other muscles 
or muscular groups. It is a test that is easily applied and that is 
especially useful in the examination of young children. 

Obstetrical Paralysis. — Paralysis of the arm is infrequent as com- 
pared with that of the lower extremities. This form might be mis- 
taken for obstetrical paralysis, but the history of the disability and its 
distribution should make the diagnosis clear. 

Prognosis. — Only in very rare instances does the disease of itself 
cause death. The prognosis as to function depends upon the area of 
the destructive disease of the cord, and upon the treatment of the 
weakened or disabled part. 

As has been stated the extent of the primary paralysis is very much 
greater than that which ultimately remains when the inflammatory 
changes about the diseased area in the cord have subsided. 






CAUSES OF DEFORMITY. 445 

The Electrical Test. — During the early stages of the disease the 
degree of final paralysis may be fairly estimated by the electrical reac- 
tion. Within a week after the initial paralysis the reaction to the far- 
adic current in the muscles and nerves is lessened and finally is lost. 
If the faradic irritability is retained in the paralyzed muscles, or if it 
is merely diminished, recovery may be predicted. The muscles which 
no longer react to the faradic irritation may still be made to contract 
by the galvanic current. In normal muscles the reaction is greatest 
at the closing of the negative pole. In the paralyzed muscles the re- 
action is slower, it requires greater stimulation and the contraction is 
greater at the closing of the positive pole. This is known as the reac- 
tion ol degeneration. The loss of faradic reaction and the change in 

Fig. 309. 




Anterior poliomyelitis. Extreme flexion deformity at the hips inducing the quadrupedal attitude. 

(Gibney.) 

the galvanic reaction indicate that the function of the affected muscle 
is lost, although certain of its fibers may in time regain their power. 

The Effects of Paralysis of Different Muscles and Groups of Muscles 
upon Function. — The interest in anterior poliomyelitis lies in its imme- 
diate and ultimate effect upon the functional ability of the individual. 
These effects may be classified as Deformity of the part directly involved. 
The general effects of weakness, deformity and loss of growth upon the 
body as a whole. 

Causes of Deformity. — The deformities of anterior poliomyelitis 
are caused : 

1. By the force of gravity. 

2. By the unopposed action of the muscles whose power remains. 



446 DISEASES OF THE NERVOUS SYSTEM. 

3. By functional use. 

All these and other less important causes of deformity are of course 
combined in most instances. The relative importance of each factor 
varies, according to the muscular group that is involved, with the age 
of the patient and with the work to which the part is subjected. The 
influence of the different factors can be studied best in the foot. 

Muscular Action and Gravity. — In by far the larger number 
of cases, one or more of the anterior muscles of the leg, dorsal flexors 
of the foot, are involved. This is illustrated by the statistics of ac- 
quired talipes, tabulated elsewhere, in which the equinus predominates 
over the varieties of calcaneus deformity in a proportion of three to one. 

If the anterior muscles are paralyzed in a child before the walking 
age, the foot drops under the influence of the force of gravity into the 
attitude of equinus. If this attitude is allowed to persist, the muscles 
on the posterior aspect of the limb accommodating themselves to the 
habitual attitude, in time become structurally shortened. In such 
cases the equinus deformity is caused by the force of gravity ; it is in- 
creased by muscular action and it is fixed by muscular adaptation. 
That deformity is not caused directly by muscular action is shown by 
the fact that it may be prevented by stimulating the paralyzed muscles 
from time to time with galvinism, or even by passive motion to the 
limit of dorsal flexion. Deformity is thus prevented, not by opposing 
muscular action, but by preventing muscular adaptation and structural 
change, by stretching the active muscles to their full limits from time 
to time. In the instance cited, gravity and muscular activity are com- 
bined in the production of equinus, but in other instances, gravity and 
muscular power may be opposed to one another. If, for example, the 
calf muscle is paralyzed while the anterior group retains its power, the 
deformity of calcaneus does not appear until the child begins to use 
the foot, when the peculiar helplessness calls attention to the disability, 
if the diagnosis has not been made before. Thus it is that equinus 
may be present when the child is still in arms, while the opposite de- 
formity develops much more slowly. 

Habitual Posture. — There are other cases in which every vestige 
of muscular power is lost, in which the foot dangles. In this class 
there is no adaptive shortening of the muscles to fix the foot in 
the habitual attitude, consequently deformity is slow in making its ap- 
pearance ; it is not often extreme, and it becomes fixed only by the 
structural shortening of the inactive tissues, the ligaments and fasciae. 
There are, of course, other causes for habitual posture than the force 
of gravity and muscular action, such as, for example, the position of 
convenience in which a weak or disabled part might be placed, but 
such causes of deformity may be considered as instances of functional 
use or rather of adaptation to local weakness. 

Functional Use as a Cause oe Deformity. — Thus far the force 
of gravity, unbalanced muscular power and the structural changes in the 
tissues have been considered in the etiology of deformity, as it might 
develop in infancy. When, however, the patient stands and walks, 



THE DEFORMITIES OF ANTERIOR POLIOMYELITIS. 



U7 



Fig. 310. 



existing deformities are exaggerated and distortions are developed and 
confirmed by the weight of the body falling on the unbalanced part, 
and by the action of the muscles in the attempt to supply the function 
of those that are paralyzed. Thus it is that deformity develops far 
more rapidly when a fair amount of muscular power remains, than 
when it is completely lost. (See talipes.) 

Subluxation. — Aside from the distortions due to the causes that 
have been mentioned, there are others caused simply by weakness ; for 
example, when laxity of ligaments 
and the failure of muscular sup- 
port permits distortion of a limb 
and subluxation or even displace- 
ment at a joint. (Figs. 311, 312.) 
Actual displacement is uncommon 
and occurs practically only at the 
hip. In such cases there is usually 
flexion deformity of the limb. The 
femur is suspended by the contract- 
ed tissues attached to the anterior 
superior spine. This unyielding 
band forms a fulcrum by means of 
which force applied at the knee 
may cause sudden displacement of 
the head of the femur inward or 
upward and backward. 

Deformities of the Upper Extrem- 
ity. — Deformities caused by paraly- 
sis of the muscles of the shoulder 
and upper arm are usually slight 
because the part is not subjected 
to the strain of weight-bearing, 
and because the force of gravity is 
opposed to muscular contraction. 
In these cases the loss of support 
and the tension on the capsule al- 
lows a considerable separation of 
the joint surfaces so that the atro- 
phied head of the humerus may be 
displaced forward or backward ; 
but there is not often fixed dis- 
placement, and consequently distor- 
tion due to this cause is very un- 
usual. 

Paralysis of the muscles of the 
forearm and of the hand is followed after a time by deformity of the 
fingers caused primarily by unopposed muscular action, secondarily by 
accommodation and atrophy. 

Deformities of the Neck. — Paralysis of one or more of the muscles 




Anterior poliomyelitis. Duration seven 
years. Showing atrophy, and slight lateral cur- 
vature of the spine. 2% inches of shortening. 



448 



DISEASES OF THE NERVOUS SYSTEM. 



of the neck may induce a paralytic torticollis. This is, however, ex- 
tremely rare. 

Deformities of the Trunk. — Paralysis of the muscles of the trunk 
may induce distortion and extreme lateral curvature of the spine. This 
curvature is not usually caused, as might at first appear, by contrac- 
tion of the active muscles and thus a bending of the trunk with a con- 

Fig. 311. 




Anterior poliomyelitis causing genu reeurvatum. (See Fig. 312.) 



vexity toward the weaker side. As a rule, the curvature is, as a whole, 
in the opposite direction. This is explained by the fact that if the 
paralysis is extensive enough to cause distortion of the trunk, and if it 
is limited to one side, the muscles of respiration on that side are also 
paralyzed or weakened so that the chest wall becomes inactive and 
collapses while the opposite side increases in volume and luog capacity 
in taking on the extra work ; thus it expands, drawing the weaker and 



RETARDATION OF GROWTH. 



449 



atrophied side into a concavity. The same effect is observed when 
the arm and the shoulder muscles are paralyzed, the spine bend- 
ing toward the side that is still active. 

Paralysis of the posterior group of muscles, if extreme, might cause 
a kyphosis. Paralysis of the muscles of the abdomen may induce 
lordosis, but in this group ot cases the lower extremities are usually 
involved and the secondary distortions due to posture and to func- 
tional use mask the direct effect of the paralysis of the muscles of the 
trunk. And again the over-use of the shoulder muscles in patients 
whose lower extremities are paralyzed, and the suspension of the 
body on crutches in walking modify the ultimate effects in these cases 
in which the paralysis is wide-spread in its area. (See lateral curvature.) 

Retardation of Growth and Secondary Deformities. — The effects of 
anterior poliomyelitis are not limited to the paralysis and to atrophy 
of the muscles, but all the component tissues of the affected limb are 
involved as well. The bones become relatively atrophied and their 

Fig. 312. 




Anterior poliomyelitis. 



Paralysis of muscles at the hip allows subluxation of the femui 
The same patient as in Fig. 311. 



growth is retarded to a degree proportionate to the extent of the par- 
alysis and to the functional disability that has resulted. It has been 
stated however that retardation of growth does not always correspond 
to the amount of paralysis. In some instances paralysis of a single 
muscle which does not seriously compromise the function of the part 
is attended with greater shortening of the limb than in other cases in 
which the paralysis is far more extensive. Thus it may be inferred 
that certain cells in the spinal cord are especially concerned in the 
growth and nutrition of the bones and that interference with the function 
of these cells may not correspond absolutely to the extent of the de- 
structive process. However this may be, it is certain that atrophy 
and retardation of growth are much greater when a limb is not used 
than when by the aid of apparatus it has been enabled to carry out, in 
part at least, its proper function. It is evident also that retardation 
of growth will be more marked during the period of rapid develop- 
ment ; thus the younger the patient the greater should be the ultimate 
inequality of the limbs. 
29 



450 DISEASES OF THE NERVOUS SYSTE3L 

Ketardatiox of Growth. — The ultimate shortening varies from 
one to three inches. In the slighter degrees of paralysis affecting the 
leg, the shortening may be less than an inch, but when the thigh muscles 
are paralyzed also, it may be much more. (Fig. 310.) This inequality 
is usually very evident in the size of the two feet. 

When both limbs are paralyzed so that locomotion is very seriously 
interfered with, the retardation of growth is especially marked and the 
contrast between the trunk of the patient and the attenuated lower ex- 
tremities is very striking. 

Secondary deformities must include besides those already men- 
tioned the compensatory distortions of the trunk that may follow 
paralysis of the limbs. Thus a short leg might cause a lateral curva- 
ture of the spine or great flexion contraction of the thigh might induce 
abnormal lordosis. As a matter of fact, the final effects of disabilities 
of this character are very complex and are influenced by many factors 
of which only a general indication is practicable. 

Treatment. — The treatment of the acute stage of anterior polio- 
myelitis is symptomatic. If the diagnosis has been made, such measures 
as would tend to relieve the congestion about the diseased area should 
be employed ; cathartics, sedatives, and counter-irritation of the spine, 
for example. When the acute symptoms have subsided, local treat- 
ment to maintain as far as is possible the nutrition of the muscles, to pre- 
vent deformity and to relieve the strain upon the weakened tissues is 
indicated. The nutrition of the parts may be improved by massage, 
by muscle beating, by the direct application of heat to the cold ex- 
tremities, and by the use of galvanism, as long as it will produce con- 
tractions in the paralyzed muscles. 

Deformity may be prevented by moving each joint to the limit of 
the range of motion in all directions several times a day and by sup- 
porting the limb with appropriate apparatus. Deformity in those parts 
in which it is favored by muscular action and by the force of gravity, ap- 
pears much more rapidly than is generally supposed. The indications 
of equinus, for example, are apparent in a very few weeks after paraly- 
sis of the anterior muscles of the leg. The first indication of such de- 
formity in this class is the discomfort caused by passively moving the 
foot toward dorsal flexion. This limitation of the range of motion 
rapidly increases, and as it increases it is confirmed by muscular adap- 
tation and finally by structural shortening. 

The Principles of Mechanical Treatment. — The object of a brace is to 
prevent the deformity due to weakness, to utilize the muscular power 
that remains and thus to enable the disabled member to carry out its 
function. As each muscle has an essential function, the paralysis of 
any muscle must be followed by a certain disability and usually by de- 
formity. Muscles vary in importance as they do in strength and the 
ultimate disability caused by paralysis may be predicted very accurately 
by one who is familiar with this function. 

Paralysis of the Anterior Muscles of the Leg. — Paral- 
ysis of the anterior leg group causes the so-called steppage gait, the toes 



MECHANICAL TREATMENT. 



451 




q^ 



^3, 



3 



drag on the floor when the limb is swung forward and this necessitates 
an awkward lifting of the knee. The result of such paralysis is equi- 
nus. Slight equinus has 

a tendency to throw the Fig. 313. Fig. 314. 

knee backward, "recur- 
vatum," in order that 
the patient may place the 
entire sole on the ground. 
More marked equinus 
obliges the patient to bear 
the weight entirely on 
the front of the foot and 
causes flexion both at 
the knee and hip. If 
but one of the muscles 
of the anterior group is 
paralyzed the tendency 
to equinus is in so far 
lessened, but there is 
an inclination to lateral 
distortion. Paralysis of 
the anterior muscles 
causes an awkward gait 
and often deformity, 
but the propelling force 
of the limb remains. 
The indication for support is simple, to prevent the foot from drop- 
ping to the extent that incommodes the patient, or practically to hold 
the foot at a right angle with the leg. 

Paralysis of the Posterior Muscles of the Leg. — If, on 
the other hand, the calf muscles are paralyzed the resistance of the foot 
is lost and it is simply dorsi-flexed when weight is thrown upon it. 
Thus the brace must be arranged to prevent dorsal flexion, and strong 
enough to support the strain which is transmitted from the foot plate 
of the brace to the front of the leg. The various weakn esses and de- 
formities of the foot and the means of treating them are described at 
length elsewhere. (See talipes.) 

Paralysis of the calf muscles not only affects the foot, but it weakens 
the knee as well, and genu recurvatum is often a secondary effect. In 
many instances therefore it will be necessary to support the knee as 
well as the ankle during the earlier stages of the treatment. 

Paralysis of the Thigh Muscles. — Paralysis of the quadri- 
ceps extensor muscle causes primarily a peculiar gait. The patient, 
unable to extend the leg upon the thigh, throws or swings it forward, 
then locks the joint by direct contact of the bones and by the resist- 
ance of the posterior tissues, by inclining the body somewhat forward 
as the weight falls upon it. In this manner again the knee may be 
over-extended. Or if extension is checked by shortening of the tissues, 



The Judson brace for paralysis of the quadriceps extensor mus- 
cle in connection with deformity of the foot. 



452 



DISEASES OF THE NERVOUS SYSTEM. 



induced possibly by habitual assumption of the sitting posture, the pa- 
tient being unable to lock the joint effectively by complete contact of 
the bones, often trips and falls because of the insecurity of the sup- 
port. When in the normal subject the weight is borne upon one 
leg in the attitude of rest, in which the muscles are thrown out of 



Fig. 316. 



Fig. 315. 




A brace for complete paralysis of the 
limb, showing a form of lock at the knee and 
a limited joint at the ankle. 



Anterior poliomyelitis. Paralysis of the ante- 
rior and posterior muscles. Right leg. 



action, the knee joint is locked, but the insecurity of this support is 
illustrated by the school boy's trick of striking the back of the knee 
with the hand when, the muscles being taken unawares, the person falls 
to the ground. This insecurity is constant when the extensor of the 
leg is paralyzed. 

Paralysis limited to the quadriceps extensor muscle is, however, 



MECHANICAL TREATMENT. 



453 



very unusual. In almost all cases some of the leg muscles are involved 
also, and the brace usually must serve to support the foot as well as 
the knee. In its ordinary form such a brace is constructed of two 
lateral upright bars, reaching nearly to the pubes on the inner and to 
the trochanter on the outer side, joined to one another by bands pass- 
ing beneath the thigh and the calf, and attached to a light steel foot 
plate. If the dorsal flexors of the foot are paralyzed the ankle joint 
is arranged to allow dorsal flexion, but to prevent extension beyond 
the right angle. If the calf muscle is paralyzed a reverse catch is used, 
or the uprights are attached directly to the foot plate without a joint 



Fig. 317. 




Brace for complete paralysis of the anterior muscles of the limb ; before and after covering. 

(Fig. 314) ; or the so-called limited joint allowing only a few degrees 
of motion in either direction is used. (Fig. 315.) (See talipes.) In 
the treatment of young children the joint is also omitted at the knee, 
the limb being firmly held in the extended position during the active 
period. (Figs. 314 and 317.) This is of advantage because the joint 
is the weakest part of the brace and soon becomes loose under the se- 
vere strain to which it is subjected. In older subjects a joint is ar- 
ranged with a spring catch, the brace being held in the straight posi- 
tion when the patient is walking about, but allowing flexion when the 
sitting posture is assumed. This is of course a great convenience. 



454 DISEASES OF THE NERVOUS SYSTEM. 

(Fig. 315.) In fitting the brace the lateral bars should be adjusted 
to support the limb without uncomfortable pressure, and the joints 
should be exactly opposite the normal centers of motion. The thigh 
and leg bands should be properly fitted to the contour of the soft 
parts so that half the limb is contained within them. These are 
smoothly covered with leather and the limb is held in position by leather 
bands that complete the circumference. Other bands are applied across 
the front or back of the limb, either to support it or to fix it firmly in 
place. In the ordinary brace without the joint at the knee, there are 
three anterior bands, one across the front of the thigh, another across 
the leg, and the third, a wide knee cap, supports the greater part of 
the strain. (Fig. 317.) 

Paralysis of the Muscles of the Hip. — The effect of paralysis 
of the muscles about the hip is difficult to describe, as in these cases many 
other muscles are usually involved. If all the muscles are paralyzed 
the thigh dangles. This is however very unusual, for the tensor va- 
ginae femoris almost always retains its power and is one of the causes 
of flexion deformity which is so often present in cases of this character. 

Paralysis of the ilio-psoas muscle makes it impossible for the pa- 
tient to flex the thigh directly. If the adductors are paralyzed he 
must lift the thigh with the hand when adduction is desired. Paralysis 
of the glutei is made evident by the atrophy and by the weakness of 
the extending power of the limb. 

The distribution of the paralysis of the muscles of the hip may be 
ascertained by placing the patient in the recumbent posture ; the leg 
is then lifted from the table, and by placing the thigh in different po- 
sitions the ability of the patient to move it may be tested, in older 
subjects by voluntary effort, in the younger ones by pricking the part 
slightly with a pin. 

General weakness of the muscles of the hip causes an awkward, 
insecure gait accompanied usually by outward rotation of the limb, 
and as has been stated there is almost always accompanying paralysis 
of other muscles of the extremity. In such cases a pelvic band must 
be attached to the leg brace. The pelvic band is made of sheet steel of 
about 18 gauge, two inches wide, fitted to the pelvis which it encircles 
midway between the crest of the ilium and the trochanter. At this 
point it is attached to the brace by a free joint. (Fig. 317.) When 
the band is accurately adjusted and strapped firmly about the pelvis, 
the necessary security is assured and the attitude of the limb in walking 
can be regulated. If greater support is desired a perineal band may 
be applied as described in the chapter on disease of the hip joint. 

If both limbs are paralyzed double braces must be used. If the 
muscles of the lower part of the back are much weakened the pelvic 
band may be replaced by a corset or some form of back brace. For- 
tunately these cases are uncommon. 

Paralytic Scoliosis. — Paralytic scoliosis requires the support of 
corsets or braces as a rule, such as are used in the treatment of other 
forms of distortion of the back. (See lateral curvature.) 



OPERATIVE TREATMENT. 455 

Paralysis of the Arm. — Paralysis of the arm is uncommon and 
treatment is rarely demanded. 

In some instances a shoulder support may be of service or a brace 
to hold the arm at a right angle if the biceps is paralyzed. If the 
muscles of the scapula retain their power the operation of arthrodesis 
might be of service in fixing the dangling joint, and the same opera- 
tion might be useful at the elbow. It is of course evident that one 
of the lower extremities, although hopelessly weakened, may be braced 
so that it may serve as a simple prop to bear weight, but as the func- 
tion of the arm is quite different, extensive paralysis of its muscles 
makes it practically useless to the individual. 

Operative Treatment. The Reduction of Deformity. — In a large 
proportion of the cases of anterior poliomyelitis the patients are not 
seen by the orthopaedic surgeon until months or years have elapsed 
since the original attack. They are then brought for treatment be- 
cause of secondary deformity often of an extreme degree. At least half 
of the cases of talipes are due to this cause and with the deformity of 
the foot are often combined other distortions varying in degree with 
the extent of the paralysis. Many of the patients hobble about on a 
distorted foot, others use crutches and in a smaller number the only 
method of locomotion is creeping on all fours. In the cases in which 
the patient has habitually used crutches alloAving the paralyzed limb to 
" dangle " there is usually marked flexion at the three joints. The 
thigh is flexed upon the pelvis, the leg is flexed upon the thigh and 
the foot hangs downward and inward (plantar-flexed) in an attitude of 
equino-varus. Xo matter how extreme the paralysis of a lower ex- 
tremity may be the limb may be made useful as a prop, when properly 
braced and this prop will enable the patient to dispense with the use of 
crutches and thus free the arms from unnecessary work. Even if both 
limbs are paralyzed they may at least serve as supports to enable the 
patient to stand erect and to propel himself with the aid of crutches. 
If the limb has been disused for a long time, the atrophy is* usually 
extreme, the bones are fragile and the growth has been greatly retarded 
as compared with those limbs in which deformity has been prevented 
and in which the weight of the body has been sustained in functional 
use. In this class of cases the first step must be the reduction of de- 
formity ; the foot must be brought to a right angle with the leg, the 
limb must be brought to the straight line, and the flexion at the hip 
must be overcome in order to enable the patient to stand erect without 
bending the spine forward into an extreme compensatory lordosis. 

Acquired deformity of the foot is far less resistant than is the con- 
genital form and by tenotomy and the proper application of force it 
may be readily straightened, usually at one sitting. 

The flexion contraction at the knee may be overcome also by careful 
and persistent manual stretching combined, if necessary, with division 
of the contracted tissues on the posterior aspect of the joint. 

The flexion deformity at the hip is usually fixed by the contraction 
of the tissues about the anterior superior spine of the ilium, including 



456 DISEASES OF THE NERVOUS SYSTEM. 

the tensor vaginae femoris muscle which is rarely paralyzed. These 
tissues together with the fascia may be divided subcutaneously, or by 
open incision if necessary ; after which the deformity may be reduced 
by gradual forcible extension of the thigh while the pelvis is fixed 
by flexing the other limb upon the body. When the contraction de- 
formities are reduced, lateral deviation at the knee is corrected, if it 
be present, in the same manner, and the bony points having been care- 
fully protected by padding a long spica plaster bandage is applied to 
fix the limb. 

The lesser degrees of deformity may be reduced by other means, for 
example, by repeated applications of plaster bandages under slight cor- 
rective force, or by manipulation, or by braces and bandaging. 

Paralytic knock knee may be overcome by the Thomas knock knee 
brace, and this brace when attached to a pelvic band is a useful form 
of support in the routine treatment of paralysis of the legs. (See 
knock knee.) 

The Thomas caliper knee brace is another cheap and useful support. 
It is of especial service when there is flexion or lateral deformity of 
the limb. (Fig. 230.) 

When distortion has been overcome and when functional use has 
been made possible by proper support, the development of active mus- 
cles which had been thrown out of use by the distortions, and of those 
in which part of the muscular substance has been retained is surprising. 
In many of these cases the distortions which developed during the tempo- 
rary paralysis had alone prevented recovery and this latent power may 
be revived even after years of disuse. Thus in many instances prog- 
nosis is impossible until the deformities have been corrected and until 
the limb, properly supported, has been enabled to resume its function. 

Tendon Transplantation. — This operation is best adapted to the treat- 
ment of distortions of the foot caused by paralysis of the muscles of 
the leg, and the procedure is described at length in that section. 

In certain cases of paralysis of the quadriceps extensor when the 
sartorius muscle has remained active, it may be utilized to better ad- 
vantage by attaching it to the insertion of that muscle, as suggested by 
Goldthwait. Muscle or tendon transplantation may be of service, in 
exceptional cases, in other situations. 

Paralysis of the muscles of the arm and hand is unusual. The 
operation of tendon shortening combined with transplantation of the 
tendons of one or more active muscles may be of service in the treat- 
ment of wrist drop, and opportunities may suggest themselves in other 
situations whenever it is possible to utilize the muscular power to bet- 
ter advantage. 

Arthrodesis. — As has been stated of tendon transplantation, arthro- 
desis is of greatest service at the ankle joint where it may serve to fix 
the foot at a right angle with the leg. (See talipes.) In exceptional 
cases arthrodesis or excision at the knee may be advisable in the 
older patients, but in young subjects the strain upon the long, weak 
lever formed by the two bones will almost always induce deformity. 



RECAPITULATION OF TREATMENT 



457 



Arthrodesis at the hip might be of service in complete paralysis of the 
pelvic muscles, at the shoulder when the muscles attached to the scapula 
are active, and in exceptional cases at the elbow and wrist to assure an 
improved position. 

Osteotomy. — In rare instan- F IG . 318. 

ces, particularly in the extreme 
deformities in the adult, oste- 
otomy of the femur at the hip 
or knee may be necessary in 
order to overcome resistant dis- 
tortion. 

Recapitulation of Treat- 
ment. — This consists in support 
and electrical stimulation of the 
muscles during the period of re- 
covery, together with a suitable 
brace to hold the limb in the best 
possible position for usefulness 
when the final extent of the par- 
alysis has become evident. With 
the support, any treatment that 
will improve the nutrition of the 
part is of service ; massage and 
muscle beating are of especial 
value. The limb in which the 
circulation is deficient should be 
protected from the cold by pro- 
per covering, and its nutrition 
may be improved by the direct 
application of heat, the hot-air 
or hot-water bath both being 
useful. Above all else, func- 
tional use, which is made pos- 
sible by apparatus, is of the first 
importance in preserving and 
stimulating whatever muscular 
power remains; and special gym- 
nastic exercises to this end may 
be employed if practicable. The 

prevention of deformity during the growing period is of great importance. 
Every morning and night the joints of the paralyzed part should be pas- 
sively moved to the normal limits in all directions in order to prevent 
the gradual limitation of the range of motion which is the first indica- 
tion of deformity. Lateral deviation of the limb may be prevented 
by passive manipulation and by the support that may be exercised by 
modification of the brace that may be employed. Braces should be 
strong, and as simple as may be in construction. Elastic bands and 
springs, applied with the design of replacing paralyzed muscles are of 




pe 

No joint at knee. For paralysis of the anterior 
thigh and leg muscles. 



458 DISEASES OF THE NERVOUS SYSTEM. 

little practical use, since they are ineffective in action, difficult to adjust 
and easily disarranged. The parent, when treatment is begun, must 
be impressed with the fact that a brace must be strong enough to 
serve its purpose even though its weight be objectionable ; that its 
period of usefulness is limited and that it must be replaced when it is 
outgrown * that the breaking of a brace from time to time is unavoid- 
able, and that such accidents, in so far as they are evidences of the 
functional activity of the patient, are favorable indications. 

Careful supervision of the patient, even though the weakness is not 
great, will be necessary during the period of growth. The contrast 
between the development and symmetry, the muscular power and prac- 
tical utility of a limb that has received this care and supervision, and 
one that has been neglected, is sufficiently striking to impress any one 
with the necessity for this tedious and apparently never-ending treat- 
ment. 

Thus, in this as in other chronic diseases and disabilities, the char- 
acter and the duration of treatment, its object and the final results that 
one may expect to attain by it, should be explained to the parents when 
the care of the patient is undertaken. 



CHAPTER XVIII. 
DISEASES OF THE NERVOUS SYSTEM.— Continued. 

CEREBRAL PARALYSIS OF CHILDHOOD. 

Spastic Paralysis. 

Cerebral paralysis or palsy is in orthopaedic practice second only 
in frequency and importance to anterior poliomyelitis. It is however 
entirely different in its distribution and in its effects. It is a form of 
disability that is characterized by motor weakness, by stiffness and 
loss of control, rather than by paralysis. It affects entire members 
and it results in atrophy, contractions and deformity. 

It may involve half the body, hemiplegia. 

It may be limited to the lower extremities, paraplegia. 

It may involve both the upper and lower extremities, diplegia. 

In rare instances but one extremity is affected, monoplegia. 

Distribution. — In 452 cases of cerebral paralysis analyzed by Peter- 
son, 1 332 were of the hemiplegic type, 73 were of the diplegic type 
and 46 were of the paraplegic type. In 121 cases observed at the 
Hospital for Ruptured and Crippled, 63 were paraplegic or diplegic 
and 58 were hemiplegic. The hemiplegic form of paralysis is usually 
acquired ; the diplegic and paraplegic forms are usually congenital. 

Etiology and Pathology. — Cerebral paralysis may be divided into 
two classes, the congenital and the acquired. 

Congenital Paralysis. — Paralysis of intra-uterine origin may be the 
result of mal-development or injury or a secondary effect of intercur- 
rent disease of the mother. Paralysis caused by injury at birth is usu- 
ally the result of rupture of blood vessels of the meninges due to pro- 
longed labor or to the pressure of instruments. 

Acquired Paralysis. — Acquired paralysis may be due to hemorrhage, 
embolism or thrombosis or to disease. Sachs 2 presents the following 
classification of causes and effects. 
Paralysis of intra-uterine origin. 

Large cerebral defects — true porencephaly. 

Hemorrhages of intra-uterine origin. Softening. 

Agenesis corticalis. 
Paralysis occurring during labor. 

Meningeal hemorrhage — very seldom intra-cerebral. Resulting 
conditions : meningoencephalitis chronica ; sclerosis ; cysts ; atro- 
phies ; porencephalies. 

1 American Text-book of Diseases of Children. 

2 Sachs, The Nervous Diseases of Children, 1895. 



460 



DISEASES OF THE NERVOUS SYSTEM. 



Paralysis acquired after birth. 

1. Meningeal hemorrhage — very seldom intra-cerebral. Embolism; 
thrombosis in marantic conditions, and occasionally from syphilitic 
endo-arteritis. Results of these vascular lesions, cysts ; softening ; 
atrophy ; sclerosis, diffuse and lobar. 

2. Chronic meningitis. 

3. Hydrocephalus. 

4. Primary encephalitis (Striimpell). 



General Symptoms. 

Motor. — The effect of the lesion of the brain and of the second- 
ary changes in the cord is to impair the voluntary control of the limbs 

supplied from the affected area, 
Fig. 319. an d at the same time the inhi- 

bition of the higher centers is 
impaired or lost. Thus, together 
with the loss of power, there is 
usually a corresponding exag- 
geration of the reflexes causing 
a spastic rigidity of the limbs. 
This induces distortion, which 
finally becomes fixed by the 
adaptive changes in the tis- 
sues. As the centers for the nu- 
trition of the paralyzed parts 
are not involved, the muscles do 
not waste and the circulation is 
but little affected. Thus the 
atrophy as compared with pa- 
ralysis of spinal origin (anterior 
poliomyelitis) is comparatively 
slight, and this together with 
the loss of growth is due rather 
to the general effects of the dis- 
ease and to the loss of function 
than to the direct influence of 
the nervous lesion. 

Mental. — In this form of 
paralysis the lesion is of the 
brain and the direct injury of 
its structure or the interfer- 
ence with its development is 
likely to cause mental impairment. This mental impairment is usu- 
ally more marked in the paraplegic or diplegic than in the hemiplegic 
form, because in the latter but half the brain is involved, and because 
the injury or disease occurs at a later period of its development. So 
also the mental development is usually less interfered with in the para- 




Congenital cerebral diplegia. Idiocy. 



CONGENITAL PARALYSIS. 



461 



plegic than in the diplegic type. For although both hemispheres were 
originally involved in all probability, yet the recovery of power in the 
arms shows that the injury was less extensive than when the weakness 
persists in one or both of the upper extremities. 

It is estimated that in 50 per cent, of the hemiplegic cases the 
patients are feeble-minded, al- 
though comparatively few (13 F IG . 320. 
per cent.) are idiotic. In the 
paraplegic and diplegic forms 
of paralysis about 70 per cent, 
of the patients are feeble-mind- 
ed and from 40 to 50 per cent, 
are idiotic. (Sachs.) 

Epilepsy is an accompani- 
ment of about 45 per cent, of 
all forms of cerebral paralysis 
and in 20 per cent, of the 
cases athetoid or associated 
movements in the paralyzed 
parts persist. (Peterson.) 




Congenital Paralysis. 

The congenital form of cere- 
bral paralysis is often seen in 
orthopaedic clinics, because the 
effect of the lesion of the brain 
in retarding both the mental 
and physical development first 
attracts the attention of the 
mother. Thus infants are 
brought for examination be- 
cause they are unable to sit or 
stand or to talk at the usual 
time. In certain instances the 
cause of the physical weakness spastic paraplegia. 

is simple idiocy. In such cases 

the vacant expression, the inability of the child to recognize even 
its mother, the extreme weakness and the absence of the spastic rigidity 
of the limbs, will make the diagnosis clear. 

In another class of cases the weakness appears to be caused simply 
by retarded cerebral development. The patient is apathetic and weak. 
In these cases also there is no evidence of paralysis, but the evident 
intelligence of the patient distinguishes this type from the idiotic class. 

In cerebral paralysis the child may be idiotic, or simply apathetic, 
or apparently normal in intelligence, but it is always weak and in the 
sitting posture the spine is usually bent backward into a long more or 
less rigid curve. It makes no effort to stand and when placed in the 






462 



DISEASES OF THE NERVOUS SYSTEM. 



Fig. 321. 



erect posture it will be noticed that the thighs are usually pressed 
closely against one another and that the feet are extended. The limbs 
are " stiff." There is a peculiar resistance to flexion at the extended 
joints, which slowly gives way under steady pressure. This is the 
characteristic spastic rigidity. (Fig. 320.) 

Deformities. — These children usually begin to stand, and to walk 
at about the third year or later with an awkward shuffling gait ; the 
limbs are usually flexed, adducted and rotated inward ; the knees 
touch one another or the legs may be crossed, while the feet turn in- 
ward in a persistent attitude of slight equino-varus. The equilibrium 

is very easily disturbed, partly because of 
the deformities and partly because of direct 
lesion of the brain. In the majority of 
the congenital cases the paralysis is para- 
plegic in its distribution ; perhaps fifteen 
per cent, are of the hemiplegic variety and 
in a somewhat larger number the paralysis 
is diplegic in distribution. (Fig. 319.) 

As has been stated, in a certain num- 
ber of cases the intelligence is not im- 
paired, but more often the patients are dis- 
tinctly feeble-minded. They are very 
nervous, easily startled, emotional and are 
often unable to speak distinctly, yet it is 
interesting to note that this peculiar emo- 
tional excitability often passes for an ex- 
treme degree of brightness of intellect and 
quickness of perception. In fact parents 
often remain unconvinced that the child is 
lacking in mental power until it reaches an 
age when comparison with other children 
makes this conclusion inevitable. 

Acquired Paralysis. 

As in the adult cases the common form 
of acquired cerebral paralysis in childhood 
is hemiplegia. About two-thirds of all the 
cases occur in the first three years of life ; 
and in about 20 per cent, of the cases the 
affection of the brain is a complication of 
infectious disease. The onset is usually sud- 
den and is accompanied in the majority of 
the cases by fever, convulsions and loss of 
consciousness. When the child regains 
consciousness the paralysis of the arm and leg is at once evident, and 
in about 20 per cent, of the cases the face is paralyzed also. 

Deformities. — At first the paralysis is a simple powerlessness, but 




Acquired cerebral hemiplegia. 



TREATMENT OF HEMIPLEGIA. 463 

soon the exaggeration of the reflexes is evident. As has been stated, 
there is a loss of voluntary power and an increase of the reflexes or 
stiffness of the paralyzed members. They are no longer competent to 
assume the more difficult attitudes and functions, and these are replaced 
by those that are simpler ; thus flexion becomes habitual. 

In typical hemiplegia the foot is plantar-flexed and adducted. The 
leg is flexed on the thigh and the thigh on the trunk, and with the 
flexion, adduction is usually combined. The arm is held against the 
body, the forearm is flexed upon the arm in an attitude midway be- 
tween pronation and supination. The hand is flexed upon the arm 
and inclined toward the ulnar side and the fingers are clasped over the 
adducted thumb. 

Disability. — The loss of power is not absolute ; in most instances 
the patient is able to walk with an exaggerated limp, dragging the 
stiffened and contracted leg which serves as a prop rather than as an 
active support. So also the control of the upper extremities is in part 
retained ; the patient is able to abduct the arm, to partly extend the 
forearm, sometimes to extend the fingers and to abduct the thumb, but 
the power to dorsi-flex the hand and at the same time to extend the 
fingers is not usually retained in a case of this character. 

Loss of Growth. — The growth of the patient as a whole is usually 
retarded, and checked to a certain extent, by the lesion of the brain. 
There is in addition a certain degree of inequality in the growth of the 
two halves of the body. This inequality is more marked in the arms 
than in the legs. Shortening to the extent of an inch in the lower ex- 
tremity is not often exceeded, but the growth of the arm and hand may 
be very markedly checked. This disproportionate loss of growth in 
the upper over the lower extremity, although it may be explained in 
part by the situation of the lesion of the brain, depends more directly 
upon the interference with function. The lower extremity is rarely 
disabled to an extent that prevents its use in locomotion, consequently 
its nutrition is preserved, whereas the same degree of paralysis of the 
arm utterly unfits it for its more difficult functions and it becomes a 
useless appendage. With the disuse of function there is a correspond- 
ing diminution of nutrition and a consequent atrophy and loss of growth. 

Extreme deformity and disability, as in the type described, is rather 
unusual. In many instances there is almost complete recovery from 
the paralysis, only an awkwardness and slowness of movement, com- 
bined with an increase of reflexes and a slight hemiatrophy of the 
body persists. In some cases a slight degree of equinus is the only 
deformity ; in others weakness of the arm may persist although com- 
plete control of the lower extremities has been regained. 

The final effect of the paralysis is almost always more marked in 
the upper than in the lower extremity ; thus when contractions and 
deformities of the lower extremity are present the arm and hand are 
often practically disabled. 

Treatment. 1 . Hemiplegia. — The treatment from the orthopaedic 
standpoint consists in stimulating the nutrition of the paralyzed parts, 



464 DISEASES OF THE NERVOUS SYSTEM. 

in preventing deformity and in improving the functional ability. The 
results of treatment are, of course, very greatly influenced by the 
mental condition of the patient. If the mental power is not impaired 
one may count upon the efforts of the patient to aid the surgeon, 
whereas if the patient is idiotic there is but little encouragement for 
active treatment. If the patient is seen before the secondary contrac- 
tions have appeared, deformity may be prevented in great degree by 
regular massage and by passive movements in the directions opposed 
to the habitual positions. If the spastic rigidity is slight the control 
of the movements of the leg may be made easier by the use of a light 
jointed leg brace attached to a pelvic baud. By this means the move- 
ments are controlled and the excessive expenditure of nervous energy 
necessary to guide the limb may be lessened. This support should be 
supplemented by massage and exercise, and in the milder type of 
paralysis the control of the limb may be greatly improved. 

In many instances the patients are not seen until late childhood, 
when the deformities have become fixed. The foot is usually turned 
inward and downward (equino- varus), there is flexion at the knee and 
often flexion and adduction at the hip, the resistance of the contractions 
being dependent upon the duration of the deformity. In such cases 
the distortions must be corrected by force and by division of more re- 
sistant tissues including often the tendo Achillis, the plantar fascia, 
and in many instances the hamstrings, and the adductors of the hip. 
The limb is then fixed in a plaster of Paris bandage for a sufficient 
time to overcome the more direct tendency to deformity. When the 
bandage is removed a brace is of service in guiding the limb, and 
regular massage and forcible passive movements together with proper 
exercises should be employed whenever practicable. In this class of 
cases the deformities may be overcome in most instances, but there is 
a tendency toward flexion at the knee, and stiffness and awkward- 
ness in movement usually persist. 

In many of the milder hemiplegic cases the only deformity is of the 
foot. This should be treated by division of the tendo Achillis and by 
support for a time until the deformity habit has disappeared. 

If the arm is but slightly affected proper exercises will greatly im- 
prove its ability. In the more extreme cases in which the fingers are 
clasped over one another, treatment is practically useless. In the third 
class in which the patient has the power of extending the fingers only 
when the wrist is flexed, the power of dorsi-flexion may be restored 
or improved by transplanting the flexors of the carpus on the radial 
and ulna border to the extensors which have been over-lapped and 
shortened to the proper extent. The transplantation of other tendons 
may be of service, but the operation is limited in usefulness for the 
reasons stated. 1 Athetoid movements of the hand and arm may be 
relieved somewhat by prolonged fixation in a plaster bandage, or by 
arthrodesis at the wrist joint. 

2. Paraplegia. — The treatment of spastic paraplegia is much more 
iTownsend, Trans. Am. Orth. Ass'n, Vol. XIII., 1900. 



TREATMENT OF PARAPLEGIA. 465 

difficult than that of hemiplegia because the disability is very much 
greater and because the mental impairment is usually more marked. 

In general the treatment in infancy is by massage and by manipula- 
tion. When the child shows a desire to walk an attempt should be 
made to relieve the spastic contractions. In certain instances complete 
correction of all deformities, followed by prolonged fixation of each joint 
in the over-corrected attitude, may be of service. (Fig. 322.) This 

Fig. 322. 




"Cerebral paraplegia, second stage in treatment. The long replaced by the short spica. This pa- 
tient at the age of eight years was unable to stand without assistance. The spastic contractions and 
deformities were overcome by tenotomies and by force, and a double long spica bandage was applied. 
This was worn for eight months. It was then replaced by the bandage shown in illustration. Six 
months^later this was removed. There is at present no deformity, and the child walks fairly well. 

may be combined with multiple tenotomies if the contractions are more 
resistant. The advantage of tenotomy, aside from the simple correction 
of deformity, is that by elongation of the tendon the response to the 
exaggerated motor impulses is lessened and an opportunity for more 
effective control is afforded. Transplantation of tendons from the 
flexor to the extensor aspect of the limb has been performed in several 
instances but the value of the procedure is still in doubt. Except in the 
very mild cases of paraplegia, braces are of little value. The trunk is 
30 



466 DISEASES OF THE NERVOUS SYSTEM. 

not as a rule deformed except in the diplegic cases in which the mental 
impairment is great. Manipulation, massage and posture are of some 
service in correcting and preventing this distortion. 

Prognosis. — It is stated by Peterson l that the patients in whom the 
paralysis is paraplegic or diplegic usually die before the twentieth 
year, and that but few of those in whom it is hemiplegic reach the age 
of forty. This prognosis applies, it may be assumed, rather to the 
extreme cases accompanied by mental impairment than to the milder 
forms. In almost all cases the patient even if idiotic is finally able 
to stand and to walk. As a rule there is for a time a gradual im- 
provement in motor power and in mental control as well. It is evident 
that in a class in which mental enfeeblement is so common and in 
which epilepsy is present in so large a proportion of cases, simple care 
and moral and mental training are of great importance. 

Orthopaedic treatment, although it has no direct action upon the le- 
sion in the brain, certainly has an indirect effect upon the mental as 
well as upon the physical condition of the patient. When deformity 
has been corrected and when contractions have been overcome, func- 
tional use requires less mental effort ; and motor control may be still 
further improved by drilling the patient constantly in simple move- 
ments. Such exercises improve the motor communications and the 
ability of the paralyzed part as well. 

Progressive Muscular Atrophy. 

Progressive muscular atrophy, as the term implies, is a progressive 
wasting of the muscles, with corresponding loss of power, terminating 
finally in paralysis and deformity. 

Under this title are included two varieties of disease. 

1. The myelopathic form in which there is primary disease of the 
spinal cord. 

2. The myopathic form in which the disease is primarily of the 
nerve terminals and the muscular fibers. 

The second variety is usually designated as muscular dystrophy to 
distinguish it from the spinal form. 

Myelopathic Paralysis or Atrophy. — The myelopathic form 
of muscular atrophy, the Aran-Duchenne type, usually begins in the 
small muscles of the hands and spreads from the periphery to the 
trunk. Fibrillary twitching of the affected and unaffected muscles 
is fairly constant and the reaction of degeneration may be present. 
The disease is practically limited to adults and from the orthopaedic 
standpoint it is of little interest. In another form, the Charcot-Marie- 
Tooth type, usually classed with the muscular atrophies, the paralysis 
may begin in the muscles of the legs, causing deformity of the equinus 
or equino-varus variety. The lesion of the cord in muscular atrophy 
is of the anterior cornua, and resembles closely that of the subacute 
form of anterior poliomyelitis. 

i Trans. Am. Orth. Ass'n, Vol. XIII., 1900. 



21 USCULAB D YSTR OPHY. 



467 



Myopathic Paralysis or Muscular Dystrophy. — The myo- 
pathic form of muscular atrophy may be preceded by apparent hyper- 
trophy (pseudo-hypertrophic muscular paralysis), it may be primarily 
atrophic, or the two forms may be combined. 

It differs from the myelopathic form in several particulars. It is a 
disease of childhood. It is often heredi- 
tary and its distribution is different. FlG 304 

The affection is divided according to 
the distribution into two main varieties. 

Fig. 323. 





Progressive muscular dys- 
trophy, showing the enlargement 
of the calves and the atrophy of 
the shoulder muscles. 



Progressive muscular dystro- 
phy, facio-scapulo-humeral type. 
Extreme lordosis and flexion con- 
tractions at the hips. 



1. The facio-scapulo-humeral type (Landouzy-Dejerine), in which 
the muscles of the face and shoulder girdle are primarily affected. 
(Fig. 324.) 

2. The juvenile form of Erb ? in which the muscles of the back and 
of the upper arms are first involved. 



468 DISEASES OF THE NERVOUS SYSTEM. 

The etiology, pathology and clinical course of the atrophic does not 
differ essentially from the pseudo -hypertrophic form. 

Pseudohypertrophic Muscular Paralysis. — Pseudo-hyper- 
trophic paralysis is characterized by progressive weakness of the mus- 
cles of the trunk and of the legs associated with apparent hypertrophy 
of the calves due to a deposit of fat in the wasting muscles. (Fig. 323.) 

The symptoms are caused by a degenerative atrophy of the nerve 
terminals and of the muscular fibers and an increase of the connective 
tissue and replacement of the muscular substance by fat. 

Diagnosis. — The interest in this latter affection from the orthopaedic 
standpoint lies in the diagnosis in the early stage of the affection. At 
this time the patient is evidently weak, he walks with an awkward, 
shambling gait and climbing stairs is especially difficult. There is 
usually an increased lordosis and a peculiar swaying or waddle, a disin- 
clination to stoop and an evident difficulty in regaining the erect pos- 
ture, and there may be discomfort or pain referred to the lumbar region. 
If the disease is advanced, the peculiar hard, resistant enlargement of 
the calves, combined, it may be, with atrophy of the muscular groups of 
the upper extremity, and weakness of the muscles of the back, makes 
the diagnosis evident, but in young children the disease may be mis- 
taken for Pott's disease, simple weakness, or postural deformity. Al- 
though there is a superficial resemblance to the general symptoms of 
Pott's disease, yet the specific signs of disease of the vertebrae, pain and 
muscular spasm, are absent. 

Weakness, a result of malnutrition or disease, is general in char- 
acter and its cause is usually apparent ; it is, of course, not accom- 
panied by local hypertrophy. Retarded cerebral development causes 
general weakness as far as inability to stand is concerned, but the cause 
is in this class also usually apparent. Postural deformities in child- 
hood always have a cause, and as one is not content to treat a deformity 
without ascertaining its cause, this search will bring to light the pecu- 
liar symptoms of the disease. 

Treatment. — In certain instances the discomfort referred to the 
back, due in part to the lordosis, may be relieved by a light spinal sup- 
port. Massage and muscle training may enable the patient to utilize 
the remaining power to best advantage. 

In the later stages of the disease there may be secondary deformities, 
most marked in the feet which may be fixed in the equinus or equino- 
varus attitude. This deformity may be corrected by tenotomy or other- 
wise, if the patient has not already become so weak that walking or 
standing is impossible. 

Hereditary Ataxia. Friedreich's Disease. 

Hereditary ataxia is an ataxic paraplegia caused by sclerosis of the 
posterior and lateral columns of the spinal cord. The early symptoms 
are incoordination and weakness of the legs; later similar symptoms ap- 
pear in the upper extremities and speech is affected. Id well-marked 



"HYSTERICAL HIP: 1 469 

cases there is usually distortion of the feet toward equinus or equino- 
varus, and occasionally a posterior or lateral curvature of the spine. In 
one case recently under treatment at the Hospital for Ruptured and 
Crippled, the rectification of the deformity of the feet was at least of 
temporary benefit. 

Neuritis. 

Localized neuritis after contagious disease or from other causes may 
result in temporary weakness or paralysis of the dorsal flexors of the 
foot, cause toe drop and finally deformity. In such cases the foot should 
be supported by a brace in normal position. This not only prevents 
deformity, but it hastens the cure by preventing tension upon and struc- 
tural lengthening of the weakened muscles. The same treatment may 
be applied for wrist drop from metallic poisoning. The hand should 
be supported by a suitable brace in the attitude of dorsi-flexion until 
the muscles have recovered their power. Obstetrical paralysis has been 
considered under affections of the shoulder. 



Hysterical Joint Affections and Deformities. 
Functional Affections of the Joints. 

So-called hysterical or functional affections may be divided into two 
groups. 

1. Those in which there is no actual disease or weakness. 

2. Those in which the symptoms of disease or injury, or of their 
effects, are exaggerated and prolonged. 

The first class of cases is small, the second is large. 

Simulation, whether voluntary or involuntary, of organic disease can 
deceive only those who are not familiar with the characteristics of the 
disability that is simulated. Every disease has certain well-defined 
symptoms which can no more be imitated by a well person than a dis- 
abled part can suddenly take on the normal appearance and function. 

" Hysterical Hip." 

The hysterical hip is supposed to simulate actual tuberculous disease. 

Diagnosis. — The symptoms of actual disease of this joint are pain, 
limp, limitation of motion due to reflex muscular spasm, muscular 
atrophy, distortion and in the later stages the local signs of a destructive 
process ; for example, heat, swelling, abscess and displacement of the 
parts, shortening of the limb and the like. As these later symptoms 
could not be simulated they need not be considered. 

In actual disease symptoms and effects follow one another in regular 
sequence and correspond closely to the pathological conditions that 
cause them. Pain is not a pronounced symptom ; it is more likely to 
be concealed than exaggerated and it is usually referred to the knee. 
Local sensitiveness is not a pronounced symptom, and it is often absent. 
Distortion of the limb when it occurs in the early stage, before the de- 



470 DISEASES OF THE NERVOUS SYSTEM. 

structive changes are advanced, is caused by reflex muscular spasm 
and whenever this distortion is great the reflex muscular spasm, which 
involves every muscle about the joint, is also great ; so that the range 
of motion in the joint is small, and motion may be absolutely prevented. 
With the distortion there is always a corresponding atrophy of the 
muscles of the limb. If pain is present it is usually worse at night 
than during the day. 

The hysterical simulation of hip disease is characterized by an ex- 
aggeration of the symptoms and by absence of the physical signs of 
disease. There is usually an exaggerated limp, great distortion, 
marked local sensitiveness and pain, but absence of muscular spasm, 
atrophy or other signs of disease. 

The essential differences between actual disease and its simulation 
may be presented more effectively by contrasting them. 

Disease. Simulated Disease. 

Pain, intermittent or absent or Patient often complains bitterly 

concealed ; referred to the knee, of pain, referred to the hip or to the 
Often worse at night. entire limb. Worse during the day. 

Local sensitiveness, often absent Often extreme, caused by the 

or caused only by deep pressure. slightest manipulation ; the skin 

is hypersesthetic. 

Limp, corresponds to the acute- Exaggerated, does not corre- 

ness of the symptoms or to the dis- spond to the physical signs, may 
tortion ; slight in the early stage, be intermittent, 
but constant. 

Distortion, slight in the early Often great in the early stage, 

stage, is dependent on the degree bears no relation to the physical 
of muscular spasm and upon the signs ; is intermittent, may disap- 
quality of the disease ; is constant pear at night ; can be reduced by 
and cannot be reduced by manipu- manipulation, 
lation. 

Muscular spasm, always present. Absent. 

Muscular atrophy, always pres- Slight or absent, 

ent. 

Local signs of a destructive dis- Absent. 

ease, often apparent at an early 
stage. 

The age of the patient, the history of the supposed disease and the 
other evidences of hysteria that are usually present, will confirm the 
diagnosis. 

The same principle applies of course to the differential diagnosis of 
simulated disease at other joints. The knee and the hip are those that 
are most often involved. 

Hysterical Deformities. 

" Hysterical Club Foot." — Local deformity distinct from simulated 
joint disease is sometimes seen. Several cases of this character in 



"NEUROTIC JOINTS: 1 471 

which the foot was distorted have been under treatment at the Hospital 
for Ruptured and Crippled, recently. The differential diagnosis is 
simple. 

Talipes is either congenital or acquired. Congenital talipes and all 
the acquired varieties, other than those of paralytic origin, may be at 
once excluded from consideration. Paralytic talipes in the vast ma- 
jority of cases begins in early childhood when it is either caused by 
anterior poliomyelitis or is one of the deformities of cerebral hemiplegia 
or paraplegia. When these are excluded, the remaining causes of de- 
formity are very limited. Every variety of nervous disease has well- 
defined symptoms. If actual paralysis is present the muscles atrophy 
and the electrical reactions are changed. In hysterical contractions the 
muscles do not atrophy and the electrical reactions are unchanged. 

" Hysterical Scoliosis." — A case was recently under observation at 
the Hospital for Ruptured and Crippled, in which distortion of the 
trunk persisted for more than a year, and uutil a suit for damages was 
finally decided. In this case there was a most exaggerated lateral 
twist of the spine so that the shoulder approached the pelvis. The 
deformity however was not fixed, but it could be completely reduced 
when the patient was in the recumbent posture. There was no par- 
alysis, no persistent spasm, no evidence of disease or injury. The de- 
formity was of a nature that could not be explained by any conceivable 
lesion, and all the signs of hysteria were present. 

Treatment. — The principles of the treatment of pronounced hys- 
teria of which simulated joint disease or deformity are but unusual man- 
ifestations are considered at length in medical and neurological works, 
and the subject does not call for especial mention here. It is evident, 
of course, that an unequivocal diagnosis must be the first and essential 
step toward cure. In this class of cases apparatus is not often indi- 
cated unless the deformity has persisted for so long a time that the dis- 
used muscles have become incapable of performing their proper functions. 



FUNCTIONAL AFFECTIONS OF THE JOINTS. 
"Neurotic Joints." 

In this class, although there is no absolute distinction between it 
and the preceding variety, there is usually a physical basis for the 
symptoms, however much they may be exaggerated. 

The patients are not usually hysterical, in fact hysteria in the ordi- 
narily accepted sense is uncommon, and although the larger proportion 
of patients are women, yet men and children are by no means exempt 
from the so-called functional affections. 

It must be borne in mind also that many of these cases are classed 
as neurotic simply because the cause of the symptoms is not apparent. 
It is only within a few years that the slighter degrees of weak foot 
and its effects have been recognized, and it is probable that such cases, 
together with anterior metatarsalgia, the painful fascia of the con- 



472 DISEASES OF THE NERVOUS SYSTEM. 

tracted foot, achillodynia and the like might be considered as neurotic 
by one unfamiliar with their symptoms. And it may be inferred that 
as diagnosis becomes more accurate the more restricted will become 
the class of cases of purely imaginary disability, in so far at least as 
the locomotive apparatus is concerned. 

A " neurotic joint " is often caused by injury. A sprain of the ankle, 
for example, may have been treated by prolonged immobilization, either 
because the patient had originally impressed the physician with the 
severity of the symptoms or because of persistent discomfort. When 
the dressing is removed there may be congestion and discoloration due 
to impaired circulation, weakness and atrophy of the muscles due 
simply to disuse, and a certain degree of infiltration and stiffness caused 
by the original injury. In cases of this character the disability may 
be prolonged because the patient or the physician mistakes the effects 
of disuse for the symptoms of serious injury or disease. When the 
diagnosis has been made treatment should be directed to increasing 
the activity of the circulation and thus the nutrition of the part, by 
counter-irritation, by massage, by passive movements, by voluntary 
exercises and the like, but cure can only be completed by restoring 
functional use. If, therefore, the disability is of long standing a tem- 
porary brace will be required to protect the part from injury, and to 
increase the patient's confidence. In milder cases it is possible that 
without support or treatment, other than an assurance of the absence of 
serious weakness, cure may be accomplished, but this is certainly unusual. 

What has been said of exaggerated disability at the ankle following 
traumatism, applies to the treatment of similar affections elsewhere. 
The knee-joint is very often the seat of so-called neurosis. Injury 
at this point in nervous children is often followed by a persistent 
flexion contraction that may continue for weeks after all signs of the 
injury have disappeared. When the attempt is made to straighten the 
knee the patient screams with pain and the muscular resistance is very 
great. In such cases the immediate rectification of deformity and the 
application of a plaster bandage to hold the limb in the corrected 
position is indicated. It must be borne in mind that the persistent 
assumption of a deformed position for weeks or months must be fol- 
lowed by certain structural changes in the contracted muscles and 
weakness in the opposing groups. Thus some assistance may be 
required in the treatment even of the purely hysterical deformities, be- 
cause of this weakness. 

In all forms of traumatic neurosis, so called, the possibility of a 
physical basis for the symptoms should be considered, the location of 
the pain or discomfort and its connection with certain movements or 
attitudes should be investigated. If such discomfort is induced or is 
aggravated always by a certain motion or attitude it is reasonable to infer 
that this has a well-defined cause, especially as the pain of a neurotic 
affection is not often of this definite character. In this class of cases 
limitation of movement for a time to the painless range of motion by 
some form of support may be indicated. 



"NEUROTIC JOINTS." 473 

Thus far injury has been considered as the starting point of the 
symptoms, but in many cases there is no history of injury. In this 
class the symptoms may have been induced by rheumatism or gout or 
rheumatoid arthritis, or by neuritis and such possible causes should be 
investigated and excluded before the diagnosis of simple neurosis is 
made. In neurasthenic patients or those who are anaemic, or over- 
worked, the pain and discomfort is often localized in the spine. The 
" neurotic spine " has been considered elsewhere. In the treatment 
of all cases of this group the general condition of the patient should 
receive consideration, and in connection with the local treatment a 
change of occupation and of scene is often of advantage. 

It is hardly necessary to insist again that an accurate diagnosis is 
the first essential of successful treatment. If this is impossible, at 
least one may by exclusion of those injuries and disabilities and dis- 
eases which are evidently not present, arrive at a general conclusion as 
to the character of the ailment, and shape his treatment accordingly. 



CHAPTER XIX. 
CONGENITAL AND ACQUIRED TORTICOLLIS. 

Torticollis. 

Synonym. — Wry Neck. 

Torticollis is, as the name implies, a twisted neck ; a distortion 
caused in most instances by active contraction or by shortening of one 
or more of the lateral muscles that control the head. Similar distor- 
tion may be due to disease of the spine, so-called false torticollis, but 
this should be classed as a symptom of the underlying disease, not as 
simple torticollis of which the distortion itself is the important dis- 
ability that demands treatment. 

Torticollis may be divided primarily into two classes, the congenital 
and the acquired. 

Congenital torticollis is a painless shortening of the tissues on one 
side of the neck, of intra-uterine origin. 

Acquired torticollis is, in most instances, accompanied in its early 
stages by local pain and sensitiveness, and by active contraction of the 
affected muscles. After a time these acute symptoms disappear leaving 
simply the deformity. Thus from the therapeutic standpoint, torti- 
collis may be classified as acute and chronic, the latter class includ- 
ing the congenital form. 

The sterno-mastoid is the muscle that is usually involved primarily, 
both in the congenital and acquired forms ; thus in typical torticollis, 
the head is drawn somewhat forward and is inclined toward the con- 
tracted muscle while the chin is slightly elevated and turned toward 
the opposite shoulder, an attitude explained by the normal action of 
the affected muscle. Irregular distortions of the head, as posterior or 
anterior torticollis due to contraction of muscles other than the sterno- 
mastoid, are however not infrequent. These will be mentioned in the 
consideration of the forms of acquired torticollis. 

Statistics. — Torticollis is comparatively an uncommon deformity. 
In a period of twenty-seven years 507 cases were treated at the Hos- 
pital for Ruptured and Crippled as contrasted with upwards of 5,000 
cases of congenital and acquired talipes. 

Acquired torticollis is by far the more common variety as is shown 
by the fact that of the 507 cases but 87 were supposed to be of con- 
genital origin. 

It is often stated that torticollis is more common in males than in 
females, and that the right side is more often affected, yet 46 of the 87 
congenital cases were in females and the contraction was of the left 
side in 38 of the 58 cases in which the affected side Avas specified. Of 



CONGENITAL TORTICOLLIS. 



475 



the entire number of cases available for comparison 246 were in fe- 
males and 198 in males ; in 236 instances the contraction was on the 
left and in 196 on the right side of the neck. From these statistics 
it would appear that the deformity is somewhat more common in fe- 
males than in males and that the left side is more often affected than 
the right. 

Congenital Torticollis. 

In most instances the deformity of congenital torticollis is slight at 
birth and it may not attract attention until the child sits or walks 
even. Thus it is often difficult to distinguish the congenital form from 
the deformity that may have been acquired in infancy, especially as the 

Fig. 325. 




Left torticollis apparently of congenital origin, showing the secondary distortions of head and face. 



patient may not be brought for treatment until the distortion has per- 
sisted for many years. 

In early infancy slight torticollis may be demonstrated by holding 
the arm on the affected side and drawing the head forcibly in the op- 
posite direction, when the shortened muscle becomes prominent beneath 
the skin, evidently restricting the range of motion. In most instances 
the sternal division of the muscle appears to be more shortened than 
the clavicular portion. 

In exceptional cases the deformity even in infancy may be extreme, 
and it may be accompanied by well-marked asymmetry of the face and 
even by distortion of the skull. In this class the shortening may in- 



476 



CONGENITAL AND ACQUIRED TORTICOLLIS. 



volve all the lateral tissues, both anterior and posterior. Slight asym- 
metry may be present at birth, and in the acquired form it is usually 
evident soon after the onset of the deformity, becoming more marked 
with its continuance. Its cause is the constrained attitude, the restric- 
tion of normal use and consequently of the blood supply, combined 
with the tension upon the tissues of the face, as is evidenced by the fact 
that it becomes less noticeable after the deformity has been corrected. 
In the well-marked cases of long standing, whether congenital or 
acquired, the face is shorter and flatter, the nose and the corner of the 

Fig. 326. 




Right torticollis, showing the displacement of the head toward the opposite 



side. 



mouth and the eyelids even on the affected side are drawn downward 
and the skull shows evidence of atrophy and deformity. 

Secondary distortions also appear in the trunk in chronic cases. 
These are rotation of the spine to compensate for the lateral distortion 
of the head and an increase in the dorsal kyphosis, " round shoulders." 
Among the minor secondary deformities upward bowing of the clavicle 
caused by the tension of the contracted muscle may be mentioned. 
(Fig. 325.) 

In the early stage of torticollis the head is tilted and is displaced 
toward the contracted tissues, but when the deformity is of longer 
standing the head following the compensatory convexity of the cervical 
spine appears to be displaced toward the opposite shoulder. (Fig. 326.) 

The compensatory deformities that have been indicated are slight in 



ETIOLOGY. 477 

infancy but they become more marked in later childhood, for in many 
instances the shortened muscle ceases to grow ; thus an original short- 
ening of half an inch, as compared to its fellow may be increased to 
two or more inches in later years. This fact emphasizes the impor- 
tance of thorough treatment as soon as may be possible after the distor- 
tion is discovered. 

As has been stated the important contraction is usually of the sterno- 
mastoid muscle, but if the deformity is uncorrected all the lateral 
tissues become shortened, so that at a later stage complete division of 
the cervical fascia as well as of the muscles may be necessary before 
the deformity can be corrected. 

Typical wry neck caused by shortening of the sterno-mastoid muscle 
is by far the most common form of congenital torticollis, but occasionally 
cases are seen in which the head is but slightly inclined to one side 
and in which the shortening appears to involve the lateral tissues in 
general rather than a particular muscle. In rare instances, although 
the deformity resembles that of typical torticollis, the greatest shorten- 
ing will be found to be of the posterior muscles on one side, particularly 
of the trapezius and the levator anguli scapulae. Thus the scapular 
may be elevated and tilted forward. This form of torticollis appears 
to be one variety of congenital elevation of the scapula. (See page 
185.) Torticollis due to defective development of the upper ex- 
tremity of the spine is a rare deformity that does not require special 
description. 

Etiology. — It may be assumed, disregarding the possible influence 
of hereditary predisposition, that congenital torticollis is, in most in- 
stances, caused by a constrained or fixed position in the uterus for a 
longer or shorter time before birth. It is in fact a simple distortion ; 
and that it has, in the majority of cases, no deeper significance is proved 
by the fact that it may be easily and completely cured by simple 
division or elongation of the contracted tissues. 

It would seem that a deformity to be properly congenital, must be 
present at birth, yet the theory, first advanced by Stromeyer, that con- 
genital torticollis is the result of injury at birth has been so generally 
accepted that it merits further consideration. 

Hematoma of the Sterno-mastoid Muscle. — Hematoma is considered 
to be, and undoubtedly is, evidence of injury. During difficult deliv- 
ery, fibers of the muscle are ruptured, usually in the upper or middle 
third of the anterior border, hemorrhage follows, which in turn is sur- 
rounded by an encapsulating area of inflammatory material. This 
forms a firm cylindrical tumor in the substance of the muscle which 
becomes noticeable two weeks after birth, or at least this is the time 
when it is usually discovered by the mother. As a rule, the tumor 
is not sensitive to pressure ; it may or may not be accompanied by 
restriction of motion in the direction causing tension on the muscle. 
The tumor remains for from three to six months, when it usually dis- 
appears, leaving no trace of its presence. 

The theory of Stromeyer, which until recently was generally ac- 



478 



CONGENITAL AND ACQUIRED TORTICOLLIS. 



cepted, is that congenital torticollis is caused by rupture of the 
muscle and by myositis about the hematoma. This inflammation may 
involve and ultimately destroy a large part of the substance of 
the muscle replacing it with fibrous tissue, which contracting, causes 
deformity. 

This theory is extremely improbable for the following reasons : 

1. Rupture of muscle elsewhere is practically never followed by 
myositis and contraction. 

2. It has been demonstrated by Heller/ that it is impossible to cause 
myositis and contraction by any form of injury to the muscles of 
animals unless it be combined with actual infection with pyogenic 
germs. 

3. Most of the cases of congenital torticollis seen soon after birth 
present no evidence of haBmatoma or injury, viz. : In 7 of 55 cases of 
supposed congenital torticollis investigated by the writer there was a 
history of injury at birth. In 48 cases no mention was made of injury. 
In the seven cases referred to the deformity was accompanied by 
hematoma or there was a history of a swelling, apparently of this 
nature ; but in two of these the haBmatoma was coincident with intra- 
uterine shortening of the muscle. 

4. Cases of hematoma of the sterno-mastoid muscle are not as a 
rule followed by torticollis. Seven consecutive cases of haBmatoma 
were examined by the writer with especial reference to this point. In 
all the evidence of violence in delivery was clear. Two were delivered 
by forceps, three were breech presentations and in two version was 
performed. In one case an arm was broken and in another paralysis 
resulted from injury to the brachial plexus. Six of the children lived 
until the swelling had nearly or entirely disappeared and in none did 
torticollis accompany or follow the haBmatoma. 

5. In certain cases a congenitally shortened muscle may be ruptured 
at delivery ; thus the haBmatoma is simply a complication of torticollis, 
not its cause. Bruns 2 has reported such a case, and two others have 
been observed by the writer, in one of which club foot was present 
also. 

6. Hard tumors of the sterno-mastoid muscle are not always the re- 
sult of injury ; myositis may be of syphilitic origin apparently occur- 
ring in intra-uterine life. In other instances tumors of fibrous or 
sarcomatous nature have been removed from the substance., of the 
muscle. 

Congenital torticollis in the majority of cases is of intra-uterine 
origin. If it follows injury at birth it is probably an indirect result of 
local pain, discomfort and irritation of the nerves or of an actual in- 
fectious inflammation of the injured part. 

Pathology. — In the ordinary type of congenital torticollis, as demon- 
strated at operations on children, the substance of the affected muscle 
or muscles is simply lessened in amount and there is a disproportionate 

1 Heller, Deutsche Zeits. f. Chir., Bd. 49, H. 2 and 3, S. 234. 

2 Cent. f. Chir., No. 26, 1891. 



ETIOLOGY OF ACUTE TORTICOLLIS. 479 

area of tendinous substance as compared to the contractile tissue. In 
other instances, the muscle may be almost entirely replaced by fibrous 
tissue, or it may be traversed by fibrous bands, or patches of scar-like 
tissue may be distributed throughout its substance. These changes, 
considered to be evidences of preexisting myositis, are probably more 
common among the acquired than the congenital form and as a rule 
they are found only in cases of long standing. Secondarily all the 
lateral tissues of the neck are shortened to correspond to the habitual 
attitude, and the compensatory curvatures of the spine in time be- 
come fixed, so that torticollis may be classed as one of the causes of 
scoliosis. 

Acquired Torticollis. 

Acquired torticollis is an affection of early life, at least 80 per cent, 
of the cases beginning in the first ten years. £->-*** ) 

As has been stated, congenital torticollis is usually a painless short- 
ening of the muscles, while acquired torticollis is, as a rule, a painful 
affection secondary to injury or disease of some of the structures of the 
neck, which causes peripheral irritation of the nerves and active con- 
traction of the neighboring muscles. Thus, as a rule, the number of 
muscles involved in the deformity is greater than in the congenital 
form ; for example, in the ordinary form of acquired wry neck the 
trapezius, which receives in part the same nerve supply, is usually 
involved together with the sterno-mastoid ; and irregular forms of dis- 
tortion caused by contraction of other groups, are not uncommon. 

Varieties. — The varieties of acquired torticollis may be classified 
conveniently as follows : 

1. The simple or mechanical form due to scar contraction following 
destruction of the skin or deeper tissues, as from burns or disease. 

2. Acute torticollis caused by direct inflammation of the muscle, by 
injury, by inflammatory affections of the surrounding parts, combined 
in most instances with irritation of the peripheral nerves, which causes 
reflex contraction of certain muscles or muscular groups. 

3. Spasmodic Torticollis. — A form of convulsive spasm, " a disorder 
of the cortical centers for rotation of the head." (Walton.) 

4. Irregular forms of Torticollis. — Paralytic, ocular, psychical and 
the like. 

The first class, that due to scar contraction, needs only to be men- 
tioned. 

Etiology of Acute Torticollis. — The second class is the most im- 
portant form of torticollis, both as to frequency and as to its effect in 
causing permanent distortion. Of this group, one of the most com- 
mon, and at the same time the least important form, is the simple 
stiff neck, supposed to be due to cold or to muscular rheumatism. Its 
onset is, in childhood, sometimes accompanied by slight fever and ma- 
laise ; the affected muscle is somewhat sensitive to pressure and motion 
or tension causes discomfort. The distortion, in great part voluntary 



480 



CONGENITAL AND ACQUIRED TORTICOLLIS. 



Fig. 32/ 



and accommodative, is of short duration as a rule. Strains and direct 
injury of the muscles of the neck may cause deformity, which usually 
disappears when the local sensitiveness has subsided. Traumatic 
hsematomata, similar to those caused by injury at birth, are sometimes 
observed in older subjects. These usually disappear after a time, 
leaving no trace of their presence. 

Another form of torticollis is secondary to cellulitis and to infiltra- 
tion following the breaking down of tuberculous cervical glands. 
This may become a permanent distortion if the deformity is allowed 
to persist or if the tissues of the neck are injured by the suppurative 
process. 

By far the most important variety of this class is the acute spastic 
torticollis due to active tonic contraction of one or more of the mus- 
cles of the neck. The exciting cause of the spasm appears to be irri- 
tation of the peripheral nerves in the naso-pharynx or in its neighbor- 
hood, and the muscles most often 
affected are those supplied in part by 
the spinal accessory nerve. Thus torti- 
collis of this form may follow tonsilitis, 
pharyngitis, measles, diphtheria and 
the like. It, may be preceded by 
" toothache " or " earache," or it may 
be an accompaniment of what appears 
to be the ordinary form of stiff neck, 
or of enlarged or suppurating cervical 
glands. In this form the torticollis is 
caused directly by tonic contraction of 
the muscles. Reflex spasm of this 
character is however often associated 
with the distortion, due primarily to 
injury of the neck or to some local in- 
flammatory process, so that a sharp 
distinction between the divisions of 
this second class is impossible. Many 
of the patients are known to be of a 
nervous temperament and over-study, 
anxiety, sudden shock and the like are 
considered to be predisposing causes. 

This variety of acquired torticollis 
completely overshadows in importance 
all other forms, as is indicated by the statistics of 2 1 2 cases treated at 
the Hospital for Ruptured and Crippled in which the cause seemed to 
be apparent. Of the 212 cases 181 may be fairly assigned to this 
class. JJj _ .... 

The apparent exciting causes of cases of acquired torticollis treated 
at the Hospital for Ruptured and Crippled is shown in the following 
table : 




Bilateral contraction of the sterno- 
uiastoids and trapezii muscles. (See 
Fig. 328.) 



SYMPTOMS OF ACUTE TORTICOLLIS. 



481 



Enlarged cervical glands 14 

Suppurating " " 41 

Scarlet fever 14 

Diphtheria 7 

Mumps 6 

Measles 2 

Sore throat 8 

Suppurating otitis 3 

Toothache 6 

Cellulitis of the neck 2 



Furuncle of the neck 1 

Cold in the neck 5 

Kheumatism 18 

Vaccinia 1 

Fever 6 

Malaria 5 

Injury to the neck 35 

Ehachitis 3 

Syphilis 1 

Cicatricial con traction 3 

Total 381 



Torticollis associated with chorea 4 

" " " epilepsy 1 

u ll u cortical irritation 5 

" " " hysteria 1 

" " u meningitis 1 

," " " hemiplegia 3 

Spasmodic torticollis 8 

' ' Functional torticollis " 8 

Total 3T 



Symptoms of Acute Torticollis. — As a rule the. distortion of the neck 
is slight at first, more noticeable at night than in the morning ; it then 
gradually increases until the 

deformity becomes fixed. In jr IG ^28. 

other instances the onset is sud- 
den, sometimes accompanied by 
fever. 

In most instances several 
muscles are more or less in- 
volved in the contraction, par- 
ticularly the sterno-mastoid and 
the trapezius, and in such cases 
the deformity is more marked 
and persistent than when the 
sterno-mastoid is alone affected. 
Less often the contraction is 
of the posterior group, " pos- 
terior torticollis," when the 
head is tilted backward and the 
chin is turned more toward the 
opposite side than in the typ- 
ical lateral form. In other 
cases the contraction appears to 
affect the small muscles that 
control the small joints at the upper extremity of the spine when the 
head may be tilted forward with but slight lateral inclination, re- 
sembling closely, except in the history, the symptomatic wry neck 
of Pott's disease. In rare instances the muscles on both sides of 
the neck may be contracted simultaneously. (Fig. 327.) The con- 
31 




Bilateral torticollis after treatment. (See Fig. 327.) 



482 CONGENITAL AND ACQUIRED TORTICOLLIS. 

tracted muscles are usually sensitive to manipulation and attempted 
rectification of the deformity causes extreme pain and is resisted by the 
patient. The child is as a rule nervous and irritable, it often com- 
plains of neuralgic pain about the contracted part which is increased 
by sudden or unguarded movements or strain ; thus " getting the patient 
to bed " is often a tedious proceeding because of the difficulty of sup- 
porting the head comfortably with the pillows. 

In many instances the affection is of short duration ; in others, 
particularly those in which the reflex spasm is aggravated by local in- 
flammatory processes, there appears to be but little tendency toward 
recovery. In such cases, after several weeks or months, the local pain 
and sensitiveness may subside together with the active spasm, but the 
deformity remains, caused by actual shortening of the muscles and 
fascia, aggravated in some instances by the destructive effect of ac- 
tual myositis. The muscles atrophy and degenerate and present at a 
later stage the same pathological appearances that are found in the 
congenital form. 

Diagnosis. — Torticollis is most often confounded with Pott's disease. 
This would seem to be hardly possible in cases of the simple painless 
contraction of chronic torticollis. In the acute form, however, there 
may be more difficulty in distinguishing between the two. The main 
points have been mentioned already in connection with Pott's disease. 
In acute torticollis the affection is of sudden onset, not preceded by the 
stiffness and neuralgic pain that usually characterize tuberculous dis- 
ease. The deformity of torticollis is almost always of the regular type, 
that is, the head is tilted toward the contracted muscles while the chin 
is rotated in the opposite direction. The spasm and contraction of the 
affected muscles are very plain and direct tension upon them is painful. 
If the contraction is relaxed by inclining the head toward the contrac- 
tion, motion in other directions will be found to be practically un- 
restricted. 

In Pott's disease the spasm of muscles is general, the deformity is 
not of a regular type, since the chin often points to the side toward 
which the head is inclined. Steady tension with the aim of reducing 
the deformity is not as a rule painful; in fact it is often agreeable to 
the patient. Finally the limitation of motion cannot be lessened by 
inclining the head toward the muscle that seems to be most contracted, 
for the reflex spasm of Pott's disease limits motion in every direction. 
As a rule the diagnosis is easily made, but in cases complicated by sup- 
puration of the cervical glands it is sometimes impossible to exclude 
Pott's disease until after the effect of treatment has been observed. 

Disease of the cervical spine, other than tuberculous, is compara- 
tively rare and resembles in its symptoms Pott's disease rather than 
torticollis. Acute arthritis of the atlo-axoid articulation that may be 
a complication of rheumatism or that may follow infectious disease is 
of sudden onset and sometimes resembles in the symptoms and de- 
formity the acute spastic torticollis, except that all the surrounding 
muscles are affected rather than a particular group ; in fact but for 



TREATMENT. 483 

the history it could not be distinguished from tuberculous disease of 
this region. 

Although the diagnosis of torticollis is simple, it is not always easy 
to determine the muscle or muscles involved in the contraction of the 
acquired form. 

The effect of unilateral contraction of the different muscles is as 
follows : 

The sterno-mastoid inclines the head toward the contraction, elevates 
the chin and turns it in the opposite direction. 

The trapezius has much the same action, but the backward inclina- 
tion and rotation are more marked. 

The action of the complexus resembles that of the trapezius, but the 
rotation is less. 

The splenius inclines the head backward and toward the contracted 
muscle but does not turn the chin in the opposite direction. 

The scaleni have the same action except that the head is inclined 
forward. 

As has been stated, in acute torticollis several muscles are often in- 
volved, but the spasm is usually greater in one or in one group than 
in another. The seat of greatest contraction may be determined by 
the deformity, by the evident spasm that resists reposition and by the 
local sensitiveness on palpation. As a rule when the primary contrac- 
tion is of the posterior group, the deformity is more marked than in 
other forms. Bilateral contraction of the muscles is rare, but it is oc- 
casionally seen. (Fig. 327.) 

Treatment. — The treatment varies according to the cause and with 
the duration of deformity. Excluding, for the present, the rare and ir- 
regular forms of wry neck there are, from the remedial standpoint, two 
forms of torticollis. 

1. The chronic form — in which the local pain and sensitiveness are 
absent, but in which there is resistant and permanent deformity. As 
has been stated, congenital torticollis is included in this class. 

2. The acute form in which the distortion is of short duration and in 
which permanent contraction may be prevented. 

The Treatment of Chronic Torticollis. — Congenital torticollis, if of 
moderate degree, can be overcome in early infancy by methodical 
stretching of the contracted parts. One person fixes the arm and an- 
other draws the head gently but firmly in the direction opposed to the 
contraction, over and over again, meanwhile massaging the tissues of 
the neck. The procedure should be repeated several times a day; it 
causes slight momentary discomfort if properly performed, but this 
ceases when the stretching is discontinued. Care should be taken also 
that the postures may, as far as possible, favor the reduction of the de- 
formity; thus while the child is in the mother's arms the head should 
be supported, and when asleep the pillow may be arranged in a man- 
ner to prevent the improper position. In this way the torticollis may 
be entirely corrected or its progress may be checked until more effec- 
tive treatment is indicated. 



484 CONGENITAL AND ACQUIRED TORTICOLLIS. 

Haematoma. — The evidence of injury at birth should be treated by 
massage with some bland ointment ; if it is accompanied by deformity 
the manipulation already described should be employed. • 

In the great majority of cases of congenital torticollis the patient is 
not brought for treatment until the deformity has become an eyesore 
to the parents. The contracted muscle is then usually an inch shorter 
than its fellow, the disparity increasing as a rule with the growth of 
the child. In such cases the immediate correction of the deformity is 
indicated, and this implies in most instances division of the contracted 
parts by subcutaneous tenotomy or by open incision. 

If the deformity is comparatively slight and if the contraction seems 
to be limited to the sterno-mastoid, and particularly to its sternal por- 
tion, one may hope to overcome the most resistant part of the con- 
traction by the subcutaneous operation. Aside from the possibility of 
wound infection, which at the present time is an argument of very 
little weight, subcutaneous tenotomy has the advantages of simplicity, 
apparent freedom from the danger which parents associate with an 
operation, and it leaves no scar behind. It is totally inadequate how- 
ever for the correction of advanced cases. 

Correction of Deformity by Subcutaneous Tenotomy. — The patient and 
the instruments having been prepared as for an ordinary operation, a 
sand bag is placed beneath the shoulders and the head is inclined so 
that the contracted muscle is thrown into relief beneath the skin. The 
sternal insertion of the tendon is seized with two fingers and the teno- 
tome is inserted beside it and passed beneath it at a point about an 
inch above the sternum. It is then divided by a sawing motion of the 
knife. Division of this part of the muscle in this situation is practi- 
cally free from danger and in the slighter degrees of deformity one can 
by vigorous manipulation and forcible traction overcome the resistance 
offered by the other tissues. If bands of fascia resist the correction, 
they may be divided by superficial nicking with the tenotome in the 
lateral region of the neck. As a rule, however, in cases of this type 
the open incision is to be preferred, as it allows the opportunity for 
free division of the contracted parts with less danger of injury to the 
blood vessels and nerves in this neighborhood. 

The Open Operation. — The incision should be made in the line of the 
muscle midway between the sternal and clavicular insertion. In the 
milder cases in childhood, it need be little more than an inch in length. 
A director may be passed beneath the tendon and on this it may be 
divided. The clavicular insertion and all bands of fascia that resist 
the normal range of motion may be divided through the incision. 

In cases of very great deformity in the adult some of the posterior 
and as well as the lateral muscles must be divided. In such instances 
the contracted parts may be divided at the upper border of the neck 
thr ou g n an incision from the mastoid process backward along the 
} ow er border of the scalp, the scar being concealed by the hair. It 
mus* be borne in mind that the object of the operation is, by means of 
divisi.° n and forcible stretching of the contracted parts, to overcome all 



THE OPEN OPERATION 



485 



restriction to normal motion, and that the failure to accomplish this 
usually explains the recurrence of deformity, which necessitates the 
use of apparatus after the operation. 

Not only should all resistance be overcome by vigorous manipula- 
tion at the time of operation, but the head should be fixed during the 
process of repair in the over-corrected position. Thus in the treatment 
of typical torticollis the chin should be turned to a point over the 
middle of the clavicle on 

the operated side and the FlG - 329 - 

head should be inclined 
toward the opposite shoul- 
der. In this attitude a 
plaster bandage should be 
applied surrounding the 
head and the thorax. 
This bandage should re- 
main until all local sen- 
sitiveness has disappeared 
and until the tendency 
toward deformity has been 
checked. This fixation in 
the over-corrected position 
is very important in child- 
hood, as an aid in over- 
coming the deformity 
habit, but it may be dis- 
pensed with in the treat- 
mentof adults. (Fig. 329.) 

The plaster bandage is 
retained from four to eight 
weeks ; when it is remov- 
ed, massage, manipula- 
tion and gymnastic train- 
ing are indicated. Twice 
a day the head should be 
forced to the extreme limit of over-correction. Traction on the neck 
in self-suspension by means of the sling used in the application of the 
plaster jacket, a regular system of exercises for the muscles of the 
neck and back and supervision of the habitual postures will usually 
assure a complete cure. If, however, the deformity habit is strong 
so that the head has a marked tendency to resume the former attitude 
some support is indicated. A simple and effective support is the 
jury mast as used in the treatment of Pott's disease with the plaster 
jacket or attached to a brace. In the treatment of children a band of 
elastic tape arranged to draw the head toward the shoulder as sug- 
gested by Sayre may be sufficient. In the after-treatment of the 
advanced cases, a support modelled after that of Brown l is effective 
and comparatively inconspicuous. 

1 Bradford and Lovett, p. 588. 




Torticollis left, showing the method of fixing the head in 
the over-corrected position. After operation. 



486 CONGENITAL AND ACQUIRED TORTICOLLIS. 

As has been stated the necessity for support, provided the deformity 
has been thoroughly over-corrected, depends upon the care that is to 
be exercised in the after-treatment. When exercises and massage 
can be efficiently employed, as a rule the support will not be required. 
In other cases it may be worn for several months with advantage. 

The principles of the treatment of the chronic or painless form of 
torticollis that have been outlined apply to the acquired, as well as to 
the congenital form, after the subsidence of the acute symptoms, when 
passive shortening has replaced active contraction. Acquired torti- 
collis is, in most instances, however, a preventable deformity; thus 
operative treatment would be rarely required had the patient received 
proper treatment. 

The Treatment of Acute Torticollis. — The insignificant form of tor- 
ticollis called stiff neck may be treated by hot applications ; a firm, 
thick collar of flexible cotton stiffened by several layers of adhesive 
plaster is an agreeable support in the more painful cases. 

In true acute spastic torticollis the cramp-like contraction of the 
muscles is secondary to some irritation elsewhere, which one should 
always try to remove, and, as has been stated, the general condition of 
the patient may require treatment as well. But the important indica- 
tion is to support the head and thus to relieve the pain and to prevent 
permanent distortion. In the early stage the support of the collar 
that has been described may be sufficient, but as a rule patients of this 
class are not seen until the distortion has persisted for weeks or months 
even, so that a more efficient form of support is required — such is 
the plaster jacket and jury mast. The elastic tension of this appliance 
overcomes the spasm and relieves the discomfort and apprehension 
which have lowered the vitality of the patient. If the spasm is the 
result of the irritation of enlarged or suppurating cervical glands, as 
is often the case, the rest afforded by the brace is an effective treat- 
ment of the cause as well as of its effect, and if suppuration is present 
this support is most convenient for the dressing that may be required. 
When the acute symptoms and deformity have been relieved, manipu- 
lation and exercises may be employed in the manner already described. 

In cases of longer standing, particularly when the posterior muscles 
are involved, the deformity may be forcibly corrected under anaesthesia 
and the head may then be fixed in a plaster dressing in the manner 
already described. This treatment may be employed at an earlier 
stage in selected cases. As a rule, when deformity has been allowed 
to persist for six months or more, its rectification will require division 
of the more resistant tissues. 

Spasmodic Torticollis. 

Spasmodic torticollis, a form of convulsive spasm of the muscles 
of the neck that is somewhat similar in its general characteristics to 
writer's cramp, 1 must not be confounded with the acute torticollis of 

1 Spasmodic torticollis is defined by Walton as a " disorder of the cortical centers for 
rotation of the head." Am. Jour. Med. Sci., March, 1898. 



TREATMENT. 487 

childhood, in which tonic spasm of the affected muscles, due usually 
to some well-defined irritation of the peripheral nerves, is the charac- 
teristic. Spasmodic torticollis is an affection of adult life. Of 32 
cases collected by Eichardson and Walton, 1 but two were in patients 
less than twenty years of age. The sexes are equally liable to the 
affection and the contraction is as frequent on one side as on the other. 

The onset of the affection is usually gradual. The first symptoms 
are often sensations of stiffness and discomfort in the muscles of the 
neck ; a " drawing sensation" and a momentary twitching or slight 
contraction which draws the head to one side. These symptoms in- 
crease slowly until the head is habitually inclined in the attitude of 
torticollis. For a time the patient can correct the position voluntarily, 
or by supporting the head with the hand can restrain the twitching of 
the muscles, but in well-established cases the head is inclined per- 
manently to one side and the convulsive spasm is uncontrollable. 
This latter symptom is the most marked peculiarity of the affection ; 
at intervals the head begins to twitch and it is finally drawn by the 
convulsive contraction of the muscles into an attitude of extreme de- 
formity. As the muscles most often affected are the sterno-mastoid 
and trapezius the attitude is usually one of typical torticollis. The 
spasmodic clonic contractions may involve the muscles of the face or 
of the chest even. They are more marked when the subject is excited 
or when sudden movements are necessary. As a rule, patients com- 
plain of neuralgic pain in the head and neck, aggravated by the cramp- 
like contractions. 

Etiology and Pathology. — The etiology is obscure. Many of the 
patients present a neurotic family or personal history, and over-work, 
shock to the nervous system and the like are cited as predisposing 
causes. 

The affection has been compared to writer's cramp as in certain in- 
stances the spasm appeared to be caused by constrained positions of 
the head necessitated by certain occupations, aggravated it may be by 
the strain of defective eyesight. 

The affected muscles may be hypertrophied from constant activity, 
and in the later stages of the affection they are, as a rule, permanently 
shortened. No characteristic changes in the nerves or in the central 
nervous system have been recorded. 

Prognosis. — There is little tendency toward spontaneous recovery. 
As a rule the spasm becomes more constant and other muscles become 
involved. 

Treatment. — It is perhaps unnecessary to state that the general 
condition of the patient and the possible local and general causes of 
the spasm should receive consideration. As a rule, however, the pa- 
tient will have exhausted both constitutional and local treatment be- 
fore coming under observation. 

In the mild and early cases the avoidance of predisposing causes 
combined with massage, systematic muscle training and in exceptional 
1 Am. Jour. Med. Sci., Jan., 1895. 



488 CONGENITAL AND ACQUIRED TORTICOLLIS. 

instances mechanical support may be of service, but in the chronic, 
severe and persistent cases of this class the resection of nerves sup- 
plying the affected muscles has alone proved to be efficient. If the 
spasm is limited to the sterno-mastoid and trapezius muscles resection 
of the spinal accessory nerve may be sufficient ; but if other muscles 
are involved or if the spasm recurs after the original operation, the re- 
moval of the posterior branches of the upper cervical nerves together 
with extensive division of the contracted muscles upon the same side 
and sometimes upon the opposite side also, may be required. 

Resection of the spinal accessory nerve was first performed by Camp- 
bell de Morgan, of London, in 1866, and since then the operation has 
been repeated many times by other surgeons with temporary or perma- 
nent benefit to the patients. According to Petit of 26 patients so treated 
13 were cured and 7 were permanently improved. In five others the 
benefit was but temporary, one died from erysipelas following the 
operation. 1 

The Operation. — The spinal accessory nerve passes downward and 
backward from the jugular foramen and enters the anterior border of 
the sterno-mastoid muscle at a point about one and a-half inches be- 
low the tip of the mastoid process. At this point it should be exposed. 
Dr. E. Eliot, Jr., from a special study of the course and relations of 
the nerve, suggests the following method : 2 

" The incision should be generous, for the nerve is situated at a con- 
siderable depth, and should extend from the mastoid process above, 
downward to one or two inches beyond the angle of the jaw. The 
anterior edge of the sterno-mastoid should then be exposed. In the 
upper part of the wound, the posterior and inferior portion of the pa- 
rotid gland may have to be drawn forward, although usually it does 
not overlap the muscle. When this is done, it is comparatively easy to 
expose by blunt dissection the transverse process of the atlas, as it lies 
directly below the mastoid process above, while immediately in front 
of this bony prominence, and running downward and forward from 
the mastoid process toward the angle of the jaw, is the posterior belly 
of the digastric. Behind this lie the main vessels of the neck with the 
spinal accessory nerve emerging from the jugular foramen and the 
operator is certain that no harm can be done to these structures as 
long as he remains superficial to the digastric belly, which in its turn 
lies at a considerable depth — in fact, at about the level of the trans- 
verse process of the atlas. 

" Owen and Petit have drawn attention to the fact that the nerve 
usually enters the mastoid muscle at a point opposite the angle of the 
jaw. I have found, however, in a large majority of cases, that on 
leaving the internal jugular it assumes a definite relationship with the 
transverse process of the atlas. Never above it, sometimes directly 
over it, usually a fraction of an inch in front of its most prominent 
part, the nerve may easily be detected in the small amount of connec- 
tive tissue that envelops it, and from this point to its entrance into 
2 L' Union Medicale, July 9, 1897. 2 Annals of Surgery, May, 1895. 



OPERATIVE TREATMENT. 489 

the belly of the muscle it may be isolated with safety, and treated by 
any suitable procedure. If, exceptionally, it should escape detection, 
the anterior border of the muscle should be drawn sharply backward 
at a point opposite the angle of the jaw, the nerve in this way put on 
the stretch, and by blunt dissection in the adipose tissue that separates 
the under surface of the muscle from the sheath of the vessels, the 
nerve may readily be exposed. Usually the nerve passes from under 
the posterior belly of the digastric, at a point Justin front of the trans- 
verse process of the atlas, to a point on the deep surface of the muscle 
just behind its anterior margin opposite the angle of the inferior max- 
illa. It is sometimes accompanied by a small artery and vein, the 
latter easily visible, the former a branch of the occipital. Rarely the 
nerve lies at a considerable distance from the transverse process of the 
atlas ; in one case as much as half an inch anteriorly. Here the nerve 
could be found at its entrance into the muscle, the landmark of the 
transverse process having failed to localize its situation. " 

Richardson suggests that if the nerve is not readily found, its posi- 
tion may be ascertained by drawing the finger nail firmly across the 
bottom of the wound, a sharp contraction following pressure upon it. 
The nerve having been isolated a section of an inch should be removed. 
Richardson advises in addition vigorous stretching of both extremities. 
After division of the nerve the spasmodic contraction relaxes and the 
muscles become flaccid, allowing the head to be brought to the normal 
position, or if the deformity has become permanent the contracted parts 
may be divided as in the ordinary form. Fixation of the head is not, 
as a rule, required. The operation should be supplemented by massage 
and by muscle training. If the spasm has been confined to the muscles 
supplied by the spinal accessory nerve, the treatment may be perma- 
nently successful, but in many instances the spasm may recur in other 
muscles. Of these, the posterior group of the opposite side is more 
often affected and a similar operation for resection of the posterior 
branches of the upper cervical nerves may be indicated. This has been 
performed with success by Smith of London, Keen, Richardson and 
others. According to Smith l the operation should be conducted as 
follows : an incision is carried downward from the occiput about three 
inches in length, parallel to and one inch from the spinous processes. 
It is continued through the trapezius to the edge of the splenius. 
The complexus is then divided and the posterior branches of the nerves 
are exposed ; those of the three upper nerves which supply the pos- 
terior rotators are then resected. 

Keen 2 operates in a somewhat different manner, by a transverse in- 
cision two and a-half inches in length from the middle line of the 
neck on a level with a point one-half an inch below the level of the 
lobule of the ear. The trapezius is divided transversely, afterwards 
the complexus, care being taken to spare the great occipital nerve. 
The posterior branch of the second cervical nerve is then resected, 
the sub-occipital nerve is then looked for in the sub-occipital triangle 
Spasmodic Wry Neck, London, 1891. 2 Annals of Surgery, January, 1891. 



490 CONGENITAL AND ACQUIRED TORTICOLLIS. 

traced down to the spine and divided. The external trunk of the 
posterior division of the third occipital Derve is then exposed below the 
great occipital and divided close to the bifurcation of the nerve trunk, 
thus the nerve supply of the chief posterior rotators, the splenius capitis, 
the rectus capitis, posticus major and the obliquus inferior is removed. 

The paralysis that follows even such extensive operations seems to 
inconvenience the patient but slightly, while the relief from deformity 
and from the constant spasm is a more than sufficient compensation for 
whatever weakness or disability may result. 

The following are the conclusions of Richardson and Walton: 1 

1. Palliative treatment, whether by drugs, apparatus or electricity, 
will rarely prove successful in well-established spasmodic torticollis. 

2. Massage may prove of value in comparatively recent cases. 

3. Resection affords practically the only rational remedy. 

4. Operation on the spinal accessory nerve may afford relief, even 
if other muscles than the sterno-cleido-mastoid are affected ; on the 
other hand the affection previously limited to the sterno-cleido-mastoid 
may spread to other muscles in spite of this operation. 

5. No fear of disabling paralysis need deter us from recommending 
operation, as the head can be held erect even after the most extensive 
resection. 

6. The most common combination of spasm is that involving the 
sterno-mastoid on one side and the posterior rotators on the other, the 
head being held in the position of sterno-mastoid spasm with the addi- 
tion of retraction through the greater power of the posterior rotators. 

7. It seems advisable in most cases to give preference to the resec- 
tion of the spinal accessory as the preliminary procedure. 

In a later communication Richardson and Walton 2 report very sat- 
isfactory final results on cases treated by resection of nerves supplying 
the muscles that were affected by the spasm on one or both sides, com- 
bined with complete division of the muscles as well, when permanent 
contraction was present. 

Kalmus 3 has reviewed the literature of the subject. In eleven cases 
of simple stretching of the spinal accessory nerve, three w T ere cured. In 
sixty-eight cases the nerve was resected ; of these twenty-three were 
cured and twenty were improved. In four there was no improvement 
and in one the patient died. In fifteen cases the resection of the nerve 
was supplemented by division of cervical nerves ; ten of these were 
cured and three were improved. In tw T o others the sterno-mastoid 
muscle was divided. 

IRREGULAR AND EXCEPTIONAL FORMS OF TORTICOLLIS. 

Paralytic Torticollis. 

One or more of the muscles of the neck may be paralyzed as from 
anterior poliomyelitis and thus a deformity, due at first to simple weak- 

1 Annals of Surgery, January, 1891. 

2 Am. Jour. Med. Sci., July, 1896. 

3 Zur Operativ Behand. Caput. Obst, Spasticum, Beitrage zur Klin. Chir., Bd. 26, 
1900. 



PSYCHICAL TORTICOLLIS. 491 

ness, and later to the permanent effects of the disability may be the 
result. 

Diphtheritic Paralysis and Torticollis. 

The muscles of the neck may be involved in paralysis following 
diphtheria. In this form the trapezii muscles are as a rule involved 
so that the head hangs forward, but occasionally the paralysis may be 
accompanied by contraction of one of the sterno-mastoids. The his- 
tory, the evident weakness, and the paralysis of the soft palate or other 
parts, which is often present, usually make the diagnosis clear. 

Cervical Opisthotonos. 

In the course of certain forms of disease of the nervous system, for 
example cerebro-spinal or basilar meningitis, the head may be draw r n 
backward by spasm of the posterior muscles. A slight degree of the 
same deformity is sometimes seen in ill-nourished infants not suffering 
from serious disease. This and the preceding distortion are of some 
importance because they may be mistaken for symptoms of Pott's dis- 
ease and they have been described in that connection. (See page 55.) 

Rhachitic Torticollis. 

During the course of acute rhachitis, particularly when the char- 
acteristic deformity of the lower part of the spine is well marked, the 
head may be tilted backward usually as a compensatory attitude, but 
occasionally slight spasm of the posterior muscles may increase the dis- 
tortion ; so also when lateral deviation of the spine is present due to 
rhachitis, the neck may participate in the deformity as in other forms 
of rotary lateral curvature. This is not torticollis, however, in the 
proper sense. 

Ocular Torticollis. 

Several cases have been recorded in which the head was habitually 
held in a distorted attitude because of defective vision or irregularity 
in the action of the muscles of the eyes. This is, however, rather an 
improper attitude than a variety of true torticollis. 1 (Fig. 143.) 

Psychical Torticollis. 

A distortion of the head, apparently due to the inability of the 
patient to control the muscles of the neck has been described by Bris- 
saud. 2 The deformity was not due to muscular spasm since it could 
be corrected by the pressure of a finger on the head. The condition is 
called by Brissaud a local paralysis of the will, a form of neurosis 
allied to neurasthenia, epilepsy, and functional spasm. 

1 Hobbv, Med. News, June 11, 1898, p. 772. 

2 These' de Paris, 1894. 



CHAPTER XX. 



DISABILITIES AND DEFORMITIES OF THE FOOT. 

General Description of the Foot and of Its Functions. 

The function of the foot is two-fold : to serve as a passive support 
of the weight of the body, and as an active lever to raise and propel 
it. For the proper performance of these functions, the foot is con- 
structed to allow elasticity under pressure, and an alternation of atti- 
tudes under strain, that protect it from injury. 

The Arches. — The most noticeable peculiarity of the foot is the ar- 
rangement of its arches. As has been suggested by Ellis and others, 



Fig. 330. 




Longitudinal section of the cast of the arch at the point A in Fig. 331 ; A, the astragalo-scaphoid 
junction ; B, the internal tuberosity of the os calcis ; C, the head of the first metatarsal bone. 

the construction and shape of the arched part of the foot may be better 
understood by considering it as half of the arch formed by the two 
feet. This complete arch may be demonstrated by making an imprint 
of the apposed feet in plaster of Paris. The plaster cast which repre- 
sents it will appear in shape somewhat like an inverted saucer, the 

Fig. 331. 




Cross section of the cast of the arches of the apposed feet. A. The internal and inferior angle of the 

astragalo-scaphoid junction. 

part of each foot that rests upon the ground forming half of an irregular 
ring. If the plaster cast is sawed into equal sections, it will be seen 
that the highest or thickest part of each division is at the astragalo- 
scaphoid junction ; from this point the arch descends sharply to the 



DESCRIPTION OF THE FOOT AND OF ITS FUNCTIONS. 493 

tuberosities of the os calcis and gradually to the outer border, beneath 
the cuboid bone, and to the metatarso-phalangeal joints. (Fig. 330.) 
A cross section of the cast will show the contour of what is sometimes 
called the transverse arch (Fig. 331), while the section through the 
long diameter will demonstrate the shape of the longitudinal arch. 
In descriptions of the longitudinal arch, it is often divided into two parts, 

Fig. 332. 




The bones of the right foot, viewed from the outer side. (Testut.) (From Gerrish's Anatomy.) 

of which the outer division is formed by the os calcis, the cuboid, and 
the two outer metatarsal bones. Of this outer arch, the highest point 
is at the calcaneo-cuboid articulation (Fig. 332), and although it is 
normally a permanent arch yet the soft tissues are forced downward 
beneath it when weight is borne, so that the outer border of the foot 
makes an imprint throughout its entire length, as contrasted with the 

Fig. 333. 




The hones of the right foot, viewed from the inner side. (Testut.) (From Gerrish's Anatomy.) 



inner and deeper arch formed by the os calcis, the astragalus, the 
scaphoid, the cuneiform and the three inner metatarsal bones. (Fig. 
333.) This division, although an artificial one, is of some service in 
calling attention to the fact that the outer or lower arch is more solidly 
braced and therefore better adapted to continuous weight-bearing than 
is the higher and more elastic inner arch. 



494 DISABILITIES AND DEFORMITIES OF THE FOOT. 

The diagram of the longitudinal arch, showing its sharp descent from 
the highest point to the center of the heel, demonstrates the fact that 
the heel is well adapted for weight-bearing, while the long anterior 
pillar composed of several bones is less strong but more elastic ; thus 
one instinctively extends the foot in descending stairs, for example, to 
avoid the unpleasant jar of direct shock received upon the heel. Of 
this anterior pillar, the third metatarsal bone is the most direct sup- 
port, while the more movable first and fifth metatarsals, more under 
muscular control, aid in balancing the weight upon the center of the 
foot. 

Both divisions of the longitudinal arch are permanent arches, but 
there are two others which are obliterated under weight ; one of these 
is that formed by the heads of the metatarsal bones, the anterior 
metatarsal arch. In the unweighted foot, the second and third 
metatarsal bones occupy a higher plane than their fellows, but when the 
erect posture is assumed, the anterior arch is depressed to allow all the 
metatarsal heads to bear their share of the weight. The other arch 
does not rest upon the ground but is formed by the internal border of 
the foot, which curves slightly outward, so that when the two feet are 
placed side by side an interval remains between them, widest at the 
highest point of the longitudinal arch, as is shown in the diagram by 
the upright section which divides the cast of the two soles from one 
another, the internal arch. (Fig. 331.) When weight is borne, 
this curved contour of the foot becomes straighter, or obliterated or 
even transformed to an arch whose convexity is internal. (Figs. 351, 
352.) 

The Foot as a Passive Support. — The foot is supported by the 
muscles, by ligaments, and by the strong plantar fascia that covers in 
the sole. When the foot is actively used, it is in great part supported 
by the muscles, but when it serves as a passive support, as in standing, 
the ligaments bear the greater part of the strain, and its normal elas- 
ticity allows the bearing surface to expand slightly as the arches are 
slightly depressed. If this normal elasticity is diminished, as is some- 
times the case, the supports of the arch are subjected to abnormal 
pressure and the individual may suffer from sensitive corns or calloused 
skin beneath the bones. Or if the ligaments allow abnormal expansion, 
the arches may become permanently depressed and as a result the range 
of motion necessary to the proper functional use of the foot, may be 
permanently restricted. 

When the statement is made that the foot broadens and that the 
arches are slightly depressed under weight, it must not be understood 
that the longitudinal arch is simply flattened by direct pressure and by 
elongation of elastic ligaments and fascia. Ligaments and fascia are 
not elastic in this sense and they are not, in the normal foot, over- 
stretched. The change in contour is the effect of normal motion in 
the joints of the foot, by which it is placed in the most favorable atti- 
tude for weight-bearing without muscular exertion — the so-called atti- 
tude of rest. 



IMPROPER POSTURES. 495 

Of the changes of contour that distinguish the foot used as a passive 
support from the one that bears no weight, the most significant is the 
obliteration of the outward curve of its internal border. This change 
is due to the fact that the astragalus, bearing the leg, rotates inward 
and downward on the os calcis until it is checked by the resistance 
of the ligaments and by the interlocking of the bones. The head 
of the astragalus thus becomes slightly prominent, the inner border of 
the foot is depressed, and an attitude is attained in which the weight of 
the body may be supported with but slight muscular exertion. In this 
attitude of rest, as Von Meyer has explained, there is general fixa- 
tion of joints of the lower extremity which makes support pos- 
sible with the least muscular exertion. The pelvis tilts slightly up- 
ward until tension is brought upon the anterior part of the capsule of 
the hip joint, the femur rotates slightly inward, so that the tibia is 
turned outward in its relation to it, and finally the tibia in turn falls 
slightly inward upon the everted foot. To unlock the joints the pelvis 
must be tilted forward or the hip must be flexed. 

The Foot in Activity. — The second function of the foot is as a 
lever to raise and to propel the body. The calf muscles supply the 
power and the heads of the metatarsal bones serve as the fulcrum on 
which the weight is to be lifted. When the foot is used as a lever, it 
should be held in such relation to the leg that the line of weight, 
passing downward through the center of the knee and ankle joints, is 
continued over the second toe or practically the center of the foot. As 
the body is lifted over the fulcrum the forefoot is turned inward in its 
relation to the leg or, more properly speaking, the leg is turned out- 
ward because the inner side of the fulcrum, formed by the first 
metatarsal bone, is longer than its outer side, thus the strain is directed 
toward the outer and stronger side of the foot. (Fig. 334.) 

In the proper walk, which is the best illustration of the leverage 
function, the feet should be held practically parallel to one another, so 
that the line of strain may fall through the center of the foot. As 
one foot is advanced it first bears weight momentarily on the heel, then 
upon its outer border ; the heel is then raised and the body is lifted 
over the toes, the great toe giving the final impulse to the step, so that 
if the walker is looked at from behind, he appears to be in-toeing at 
the termination of each step. Thus, during the walk, there is an al- 
ternation of postures, and the foot, under muscular control, assumes 
the attitudes most opposed to that of passive support. 

Improper Postures. — The alternation of postures and the leverage 
action of the foot are by no means necessary to simple progression ; 
for example, both feet might be fixed in plaster bandages yet walk- 
ing would be possible, just as it is possible on two wooden legs. In- 
deed, an approximation to such a manner of walking is often seen, in 
which the feet are practically held in the passive attitude, the weight 
being borne upon the heels. Such a walk is necessarily jarring and 
ungraceful, and if it is not the result of weakness and deformity it pre- 
disposes to them because of the disuse of the proper function of the foot. 



496 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



One means of making the leverage function difficult is the custom 
of turning the feet outward. Outward rotation of the feet is normal 
in the passive attitude of weight-bearing, because it enlarges the base 
of support, locks the joints and throws the strain upon the ligaments 
to relieve the muscles. On this very account it is the improper atti- 
tude for activity because the strain falls upon the inner border of the 
foot, or to the inner side of the fulcrum, and makes the proper exer- 
cise of muscular power and alternation of postures impossible. In 
other words the attitude normal when the foot is used as a passive 
support is abnormal when it is in active use. 

The Movements of the Foot. — The junction between the foot and 



Fig. 334. 



Fig. 335. 




Illustrates the involuntary adduction of the The improper attitude of outward rotation in which 
forefoot, due to the obliquity of the metatarsus, there is disuse of the leverage function, 

in the proper attitude for walking. 

the leg is made by means of the astragalus, a bone which is not inti- 
mately connected with either part, since it moves upon the leg and 
upon the foot, and to it no muscles are attached. 

The movements of the foot are four in number : Dorsal flexion ; 
plantar flexion ; adduction ; abduction. 

Simple dorsal and plantar flexion are confined to the ankle joint, but 
complete plantar flexion is combined with slight adduction, and dorsal 
flexion with abduction, because the external facet of the astragalus 
allows a greater range of motion on the external malleolus than is per- 
mitted about the internal malleolus. 

The range of motion at the ankle joint is from sixty to eighty de- 
grees ; thus dorsal flexion to ten or twenty degrees less than the right 



THE MOVEMENTS OE THE FOOT 



497 



angle, and plantar flexion fifty to sixty degrees more than the right 
angle. (Figs. 336, 337.) 

Adduction and abduction of the foot are carried out in the medio- 
tarsal and sub-astragaloid joints. 

Adduction, the motion of turning the foot inward in its relation to 
the leg, is always accompanied by inversion of the sole or supination, 
because of the shape of the joint surfaces between the astragalus and 
os calcis, where the greater part of the motion takes place. Simple 
adduction and abduction without supination or pronation is possible to 
a^very limited extent in the medio-tarsal joint. Its range may be 
tested by fixing the heel, when the forefoot may be moved slightly 
back and forth upon the astragalus and os calcis. The range of mo- 
tion in the sub-astragaloid joint is twice as free as in the medio-tarsal 



Fig. 336. 



Fig. 33, 





Voluntary dorsal flexion. Voluntary plantar flexion. 

In these attitudes the astragalus moves with the foot upon the leg bones, as contrasted with adduction 

and abduction in which the center of motion is below the astragalus. 



joint. The character of the motion between the astragalus and os 
calcis is rotation on an axis passing through the upper and inner part 
of the head of the astragalus, downward and outward to the outer 
tuberosity of the os calcis. Thus for all practical purposes, adduction, 
inversion and supination are synonymous terms : the same is true of 
abduction, pronation and eversiou. Outward rotation is, however, 
quite distinct, since the center of motion is at the hip joint. 

In the movement of adduction of the foot, the astragalus is fixed 
between the malleoli, and upon it the os calcis glides forward and its 
anterior extremity turns slightly inward ; the sustentaculum tali moves 
backward, its inner superior surface is elevated and its external sur- 
face is depressed. Meanwhile the forefoot, following the motion of 
32 



498 



DISABILITIES AND DEFORMITIES OF THE FOOT 



the os calcis, is carried inward about the head of the astragalus ; its 
inner border is elevated and its outer border is depressed, so that the 
sole looks inward and downward. In this attitude all the arches are 
ncreased in depth. (Fig. 338.) 

In abduction the bones move upon one another in the reverse direc- 
tion, the curves are lessened and that of the inner border is obliterated. 
(Fig. 339.) 

The extreme of adduction is only possible in the position of plantar 
flexion, because in this position the adduction possible at the ankle 
joint, in part due to the contour of the astragalus and in part to the 

Fig. 339. 



Fig. 338. 





Voluntary adduction. Voluntary abduction. 

In these postures the foot moves upon the astragalus which is practically fixed between the mal- 
leoli. Adduction, the turning of the foot inward in its relation to the leg, is always accompanied by ele- 
vation of its inner and depression of its outer border. This is known as supination or inversion of 
the foot. The reverse of this attitude — pronation or eversion — is an accompaniment of abduction as is 
illustrated in the figures. 

greater mobility allowed in the joint when the narrow posterior border 
of the astragalus is alone in contact with the malleoli, is added to the 
adduction which the joints of the foot permit. 

Extreme abduction is attained in the attitude of dorsi-flexion, its ex- 
tent being about one-half that of adduction ; the entire range of motion 
between the two extremes being about forty-five degrees. 

In this description the foot is considered as moving on the leg, 
but in the attitude of rest the foot becomes the fixed point and the 
astragalus moves upon the os calcis in the manner and to the position 



THE MOVEMENTS OF THE FOOT 



499 



already mentioned in the description of abduction, i. e., it slips down- 
ward and forward and turns inward, and at the same time the anterior 
extremity of the os calcis turns slightly inward and downward, and 




Fig. 341. 




The direct dorsal flexors. 

Tibialis anterior of right side : outline and Peroneus tertius of right side : outline and 

attachment-areas. (Gerrish.) attachment-areas. (Gerrish.) 

its inner border is depressed. Corresponding to this movement, as the 
inner border of the foot becomes straight or bulges inward, the scaphoid 
is forced forward and downward and the longitudinal arch is depressed. 



500 DISABILITIES AND DEFORMITIES OF THE FOOT. 

Fig. 342. Fig. 343. 



/ 



The calf muscle. The plantar flexor. 
Gastrocnemius of right side : outline and Soleus of right side : outline and attach- 

attachment-areas. (Gerrish.) 



ment-areas. (Gerrish.) 



THE MOVEMENTS OF THE FOOT. 



501 



As has been mentioned the turning of the leg inward and the corre- 
sponding turning of the foot outward in its relation to it, locks in a 
manner the ankle joint and at the same time throws the strain upon 



Fig. 344. 



Fig. 345. 





Peroneus longus of right side : outline 
and attachment-areas. (Gerrish.) 



The direct abductors. 



Peroneus brevis of right side : outline 
and attachment-areas. (Gerrish.) 



the ligaments, so that standing in the erect posture is possible with but 
little muscular exertion. (Fig. 351.) 

To put it in a simpler manner, the leg supporting the weight of the 



502 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



Fig. 346. 





The most important adductor. 

Tibialis posterior of right side : 
outline and attachment-areas. The 
most of the muscle is represented as if 
seen through the bones. ( Geebish. ) 



body has a tendency to tilt the foot over 
toward the inner side and to evert the 
sole ; thus, under increasing superincum- 
bent weight, the point of greatest pressure 
on the sole shifts from its center and outer 
border toward the inner border. If on the 
other hand the body is raised upon the 
toes, the arch is relieved from strain and 
the weight falls upon the front and outer 
part of the foot. Plantar flexion and ad- 
duction represent, as contrasted with the 
passive attitude of supporting weight, the 
attitude of activity in which the foot is 
supported and controlled by the muscles. 

The Function of the Muscles. — The 
most important function of the dorsal 
flexors is to lift the foot as it is swung 
forward, while the plantar flexors serve in 
the active propulsion of the body. The 
difference in function is shown by the rela- 
tive strength of the two groups, the plantar 
flexors being five times the stronger; in fact, 
the calf muscle (gastrocnemius and soleus) 
alone is three times as strong as all the other 
muscles of the foot combined. It is prac- 
tically the leverage muscle, the others serv- 
ing more especially to fix and to hold the 
forefoot, or fulcrum, in its proper relation 
to the leg. (Figs. 342, 343.) 

The muscles that most directly sup- 
port the inner arch of the foot are the 
tibialis posticus and anticus, whose ten- 
dons meet in their insertion in front of 
the astragalus in the form of a V. The 
tibialis anticus supports the internal bor- 
der of the foot from above, and the posti- 
cus is the most powerful adductor. (Figs. 
340, 346.) 

The flexor longus pollicis, passing direct- 
ly beneath the sustentaculum tali, aids in 
supporting the weak part of the foot and 
its position demonstrates the importance of 
the proper functional use of the great toe. 
(Fig. 350.) 

The peroneus longus and brevis sup- 
port the outer arch and the former binds 
the foot together and holds the great toe 
firmly against the ground, thus it indi- 
rectly supports the longitudinal arch 
against direct pressure. (Figs. 344, 345.) 



THE FUNCTION OF THE MUSCLES. 503 

The relative strength of the muscles and their functions is shown 
in the following tables : l 

Dorsal Flexors of the Foot : Strength reckoned in kilogrammeters. 

Tibialis Anticus 0.871 

Extensor Longus Digitorum 0. 280 

Extensor Longus Pollicis 0. 155 

Peroneus Tertius 0.087 

1.393 
Plantar Flexors. 



The calf muscle 



(Soleus 3.256 . 

{ Gastrocnemius 2.831 

Flexor Longus Pollicis 0.218 

Peroneus Longus 0. 118 

Tibialis Posticus 0.094 

Flexor Longus Digitorum 0. 078 

Peroneus Brevis 0.055 

67650 

Relative Strength of the Supinators of the Sub-Astragaloid Joint. 

Strength. Weight of the Muscles. 

Soleus 1.021 157.0 Grammes. 

Gastrocnemius 0.709 120.0 " 

Tibialis Posticus 0.337 39.6 " 

Flexor Longus Pollicis 0.172 33.2 " 

Flexor Longus Digitorum 0.123 12.3 " 

2~362 362~T " 

Relative Strength of the Pronators of the Sub-Astragaloid Joint. 

Strength. Weight of the Muscles. 

Peroneus Longus 0.282 24.0 Grammes. 

Peroneus Brevis 0.192 16.5 " 

Extensor Longus Digitorum... 0.164 18.2 " 

Peroneus Tertius 0.067 3.5 " 

Extensor Longus Pollicis 0.045 12.3 " 

Tibialis Anticus 0.021 49.2 " 



0.771 123.7 

Relative Strength of the Supinators of the Medio -Tarsal Joint. 

Tibialis Anticus 0.238 

Tibialis Posticus 0.078 

Flexor Longus Pollicis 0. 034 

Flexor Longus Digitorum 0. 033 

Extensor Longus Pollicis 0. 030 

67413 

Relative Strength of the Pronators of the Medio-Tarsal Joint. 

Peroneus Longus 0.162 

Peroneus Brevis 0. 090 

Extensor Longus Digitorum 0. 085 

Peroneus Tertius 0.033 

370 

It will be noticed that the strength of the pronators and supinators 

1 Uber die Arbeitsleistung der auf die Fussgelenke Wirkenden Muskeln, R. Fick 
Leipsic, 1892. 



504 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



(abductors and adductors) of the medio-tarsal joint is*~nearly equal, 
and that the great preponderance of power of the supinators of the 
sub-astragaloid joint is owing to the fact that the calf muscle is a 



Fig. 347. 



Fig. 348. 



! 





Extensor proprius hallucis of right side : out- 
line and attachment-areas. ( Gerrish. ) 



Extensor longus digitorum of right side : out- 
line and attachment-areas. (Gerrish.) 



supinator. When the foot is at a right angle with the leg, the power 
of the calf muscle not being utilized, the pronators are stronger than 
the supinators. It will be noticed also, that the tibialis anticus muscle, 



THE FUNCTION OF THE MUSCLES. 

FlG - 349 - Fig. 350. 



505 






Flexor longus digitoruni of right side • 
outline and attachment-areas. The muscle 
is represented as seen from in front 
through the hones. ( Geeeish. ) 



Flexor longus hallucis of right side : 
outline and attachment-areas. The mus- 
cle is represented as seen from the front 
through the hones. (Gereish.) 



506 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



which supinates the niedio-tarsal joint, is reckoned among the pronators 
of the sub-astragaloid joint. 

The Foot Considered as a Mechanism. — In the study of the de- 
formities, and particularly of the functional weaknesses of the foot, 
one must never lose sight of the fact that it is a machine, subject to 
the same mechanical laws that govern other machines, and that its 
deformities and disabilities, its relative strength or weakness, maybe 
appreciated by comparing it with the normal standard. As in other 
machines, marked deformity or distortion is evident at a glance, even 



Fig. 351. 




Fig. 352. 




An attitude that simulates flat foot. 
(See Fig. 353. ) 



Fig. 352, compared with Fig. 351, will 
illustrate the voluntary protection of the 
foot from over-strain. 



though the apparatus is not in use, but functional ability can be judged 
only by the manner in which active work is performed. 

As has been stated, the foot is, in activity, a lever, by means of 
which the weight of the body is lifted and propelled. If it is loosely 
constructed or insufficiently supported by the ligaments, it is evident 
that it can not be properly controlled by the muscles. If, on the other 
hand, the muscular power is insufficient, it is evident also that the 
weight of the body can not be lifted and properly balanced upon it. 
The structure of the foot may be normal and its muscles may be of 
normal strength yet the strain placed upon it may be disproportionately 



THE WEAK FOOT. 



50" 



great. 



Fh;. 353. 



This strain may be actual over-weight, or the over-work of a 
laborious occupation, but more often the machine is over-worked simply 
because it is subjected to mechanical disadvantages in the performance 
of its functions, by the assumption of improper attitudes. 

An improper attitude is one that limits or lessens the range of mo- 
tion, and the alternation of postures, that protect the foot from 
over-strain. One of the most common of such attitudes is, as has been 
mentioned, that of turning the feet outward in walking, thus the ful- 
crum being displaced outward, the strain falls through the inner and 
weaker side of the foot. As a consequence of the improper attitude 
there is usually, to a greater or less 
degree, disuse of the active leverage 
function of the foot ; the active lift 
of the calf muscle is replaced by 
exaggerated flexion at the knee, the 
foot being used somewhat as if it 
were a movable pedestal. (Fig. 
335.) 

This disuse of active attitudes 
may be unnecessary, just as the out- 
ward rotation of the feet with which 
it is associated is a habit, a habit 
that is often the result of improper 
teaching. On the other hand, the 
habitual assumption of the passive 
attitude may be induced by injury 
or disease of the foot, or by corns 
or bunions, or by improper shoes. 

Under such conditions the strain of the leverage function increases 
the discomfort, consequently it is discontinued. It must not be 
inferred that such improper attitudes lead directly to weakness and 
discomfort, for in most instances, an ungraceful carriage and' gait are 
the only ill effects. The improper attitudes must, however, lessen the 
power and resistance of the foot and they must be reckoned, therefore, 
among the predisposing causes of disability and deformity. 

The passive attitude, it will be remembered, is the attitude of rest, 
in which the ligaments bear the greater part of the strain and in which 
the arches of the foot are depressed or obliterated. 




Typical " flat foot " of moderate degree, il- 
lustrating the componeut elements of abduc- 
tion and depression of the arch. 



The Weak Foot. 

Synonyms. — Splay Foot, Flat Foot. 

This introduction leads naturally to the consideration of the most 
important of the acquired disabilities of the foot, a disability whose 
most important characteristic in the mildest and in the most advanced 
type is the persistence of the jwssive attitude, or an approximation to 
it, in place of active motion and alternation of posture. Disuse 
of function is followed by restriction of motion, particularly in the 



508 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



Fig. 354. 



Fig. 355. 



range of adduction and plantar flexion, and finally by persistent de- 
formity , a deformity which is simply an exaggeration of the normal 
posture assumed when the foot supports weight. (Fig. 35.1.) This is 
the so-called flat foot. (Fig. 353.) At first glance, it may seem 
that the depression of the arch is the most noticeable peculiarity in a 
well-marked case of flat foot, and that the popular name is therefore 
an appropriate term, but on closer examination it will be evident that 
the normal relation between the leg and the foot is changed. This 
change, which from the functional standpoint is of far greater impor- 
tance than the depth of the arch may be analyzed as follows : 

The Anatomy of the Weak Foot. — 1. The leg is displaced inward 
so that the weight falls upon the inner side of the foot ; 2. The leg is 
rotated inward, so that a line drawn through its center, prolonged 
from the crest of the tibia, instead of falling over the second toe now 
points inside the great toe, or even over the center of the internal bor- 
der of the foot. (Figs. 353-356.) 

It has been stated that under normal conditions in the. act of passive 
weight-bearing, the astragalus rotates downward and inward upon the 
os calcis, depressing its anterior and internal border until the move- 
ment is checked by the strong ligaments connecting the bones, the cal- 

caneo-scaphoid, the deltoid 
and the interosseus ; in other 
words the leg has a tendency 
to slip downward and inward 
from off the foot. In the 
weak foot this inclination 
has become an accomplished 
fact, for the normal movement 
has become so exaggerated by 
the distention of the ligaments 
and by the weakness of the 
supporting muscles that an 
actual partial dislocation has 
taken place. The astragalus has rotated and slipped far to the inner 
side of its normal position and to an attitude of exaggerated rotation 
and moderate plantar flexion, so that its head can be plainly felt on 
the internal border of the foot. The os calcis has been forced into an 
attitude of pronation. Its anterior extremity is depressed and turned 
slightly inward and its internal border is lowered. (Fig. 355.) 

The scaphoid bone has been depressed with the head of the astraga- 
lus, although to a less degree, and has been forced further away from 
the os calcis, and with it the entire inner border of the foot is depressed 
also. Thus the depression of the arch is always accompanied by a 
bulging inward of the inner side of the foot. 

The typical flat foot is, as it were, broken in the center (Fig. 366), 
the posterior division having turned inward and downward ; that is, 
the astragalus has rotated inward and downward to an extreme degree 
and has slipped from off the os calcis. The latter bone, although 





The relation of the 
astragalus to the os cal- 
cis. 



The relation of the 
astragalus and os calcis 
in flat foot. 



1HE WEAK FOOT. 



509 



Fig. 356. 



forced outward in its relation to the astragalus, still turns inward 
slightly, while the forefoot in its relation to the leg is greatly abducted. 
The dislocation may be so extreme that the entire sole of the foot rests 
upon the ground, and a callus even may be found at the point that 
usuallv represents the highest point of the arch, which now supports 
the greatest burden. 

In this change of relation between the bones the arched part of the 
foot, or waist, appears much broader than normal, even broader than 
the front of the foot ; the heel projects, the external malleolus is de- 
pressed and carried forward by the 
rotation of the leg and is much less 
prominent than normal; the internal 
malleolus is more prominent and with 
the astragalus it overhangs the bearing 
surface of the sole. The entire ma- 
chine is twisted and out of gear, its 
motion is therefore very much re- 
stricted. It is manifestly impossible 
for the patient to adduct the forefoot, 
that is to turn it inward about the 
head of the displaced astragalus. 
Plantar flexion is also much limited, 
because of the permanent position of 
adduction and plantar flexion that the 
astragalus has assumed. Dorsal flex- 
ion, on the other hand, although it is 
actually restricted, may appear to be 
abnormally free, because the forefoot is 
abducted and slightly dorsi-flexed upon 
the head of the astragalus. (Fig- 353.) 

The disability and its accompanying 
deformity, is found in every grade of 
severity. Pain begins when, the sup- 
port of the muscles being insufficient, 
the ligaments begin to give way under 
strain, allowing the bones to occupy an 
abnormal relation to one another. It is 
evident, therefore, that the individual 
in whose foot the arch is well formed 
and whose ligaments are firm, will suffer from the symptoms of strain 
long before the arch has been depressed or deformity has become appa- 
rent; also that the lateral inward bulging, characteristic of advancing de- 
formity, must be very great before the arch is completely flattened. In 
this type the prominent deformity is lateral displacement (valgus). On 
the other hand, if the individual has inherited a low arch, as is charac- 
teristic of certain races, or if, as the result of weakness in early life, the 
arch has been depressed or has never formed, accommodative changes 
in the bones Avill have taken place during growth, so that the flat foot 




Weak feet, showing the inward rota- 
lion of the legs when the abducted feet 
are placed side by side. 



510 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



Fig. 35^ 



of this type will not be attended with as much change in its relation to 
the leg, and therefore, disturbance of function, as in the typical case 
that has been described. This latter class of cases exemplifies the 
popular type of flat foot that may exist without pain or disability and 
in which the most noticeable peculiarity is the obliteration of the arch 
(planus). (Contrast Figs. 357 and 358.) 

In certain instances, abnormal laxity of ligaments allows deformity 
of the valgus type when weight is borne, yet the foot, controlled by 
efficient muscles, may be apparently normal in functional ability, while 
in other cases in which the ligaments are resistant and yet are sub- 
jected by insufficient muscular protection to over-strain, disability and 

pain may precede noticeable deformity. 
It is very evident that the lowering 
of the arch is of secondary importance 
in the deformity and that the popular 
significance of painful flat foot, as an 
inherited and irremediable weakness, 
is most misleading. Yet it seems to 
have governed the treatment of the dis- 
ability until very recently. On the one 
hand, the early cases were overlooked 
because the foot was not flat, while 
those in which the deformity was more 
advanced were simply neglected or 
were treated by simple supports be- 
neath the arch or by operation, with- 
out regard to the loss of function, and 
therefore without hope of ultimate cure. 
As has been stated, there is one 
feature common to every grade of 
the so-called flat foot ; the foot 
regarded as a machine is weak, as 
compared to the normal standard — 
weak because of the persistence of 
the attitude of rest and relaxation, as contrasted with that of activity 
and strength, and weak because the proper relation between the power 
and the fulcrum is changed. Even the inherited flat foot or the flat 
foot which has never caused symptoms, is weak in the sense that, in 
use, it lacks the spring and elasticity characteristic of the perfect machine. 
The term weak foot may be used, then, to indicate all types of the dis- 
ability. In one weak foot the arch has disappeared (Fig. 358) ; in 
another w r eak foot the arch is of normal depth but the foot is abducted 
or pronated in its relation to the leg. (Fig. 357.) In one case the 
deformity appears only under weight ; in another the foot is held rigidly 
in the deformed position by muscular spasm. In one instance there 
may be great deformity without pain ; and in another, disabling weak- 
ness and pain without deformity. In one case the foot is unable to 
perform its functions because of its inherent weakness, in another 




Weak feet, arch not depressed. 



ETIOLOGY. 511 

the disability may be due simply to the improper use of a normal 
structure. 

Pathology. — Supposing the foot to have been normal before it began 
to break down, it is evident that such deformity could not have been 
acquired without marked changes in its internal structure, and that its 
progress must have been attended with symptoms of discomfort and 
pain. In a general way, these changes are such as have been indicated 
by the description ; the ligaments on the internal aspect of the foot and 
of the ankle joint are weak and distended ; the unused portions of the 
articular surfaces of the joints may be denuded of cartilage, while new 
facets may have formed to accommodate the changed relations of the 
bones. For example, the external malleolus may be in direct contact 
with the os calcis ; evidences of injury and of abnormal pressure may 
be found in the thickened periosteum, in formation of osteophytes, 
while the internal structure of the bones has been changed as well, to 
adapt itself to the new conditions. The muscles which are no longer 
used in the leverage function, the plantar flexors and adductors, have 
become atrophied, a change that is made evident by the shrunken calf. 
The muscles on the inner border of the foot have been over-stretched, 
while those on the upper and outer part have become shortened and 
contracted. Such a foot represents an extreme, it may be an irreme- 
diable degree of deformity. The machine is completely broken down, 
it can no longer perform its proper function, it is even less efficient 
than the wooden foot, because use is attended by discomfort. 

Etiology. — In all cases the actual symptoms of pain and disability 
are due to a disproportion between the burden or strain and the ability 
of the machine to perform it. 

This theory accounts for the fact that the weak foot, although very 
common in childhood, does not as a rule, cause troublesome symptoms 
until adolescence, when the Aveight and strain put upon it are increased. 
It explains why the foot, which may be fairly normal in structure 
breaks down often in later adolescence or early adult life when the con- 
tinuous strain of regular occupation is undertaken. It is evident also 
that an occupation that requires the long continuance of the passive 
attitude, that of waiters, cooks and bar-tenders for example, exposes 
the feet to greater strain than one which permits alternation of postures 
and that the symptoms are likely to be more severe and the deformity 
to be greater among those who are obliged to labor than among those 
who are not. Over-work or strain, of occupation or otherwise, may be 
temporarily disproportinate because of general weakness, as for example, 
during pregnancy or after recovery from exhausting disease ; or because 
of local injury or disease of the foot itself which weakens it directly 
or induces improper attitudes. On this theory one may very easily 
explain what has proved such a stumbling block for students, viz., that 
there is no constant relation between the degree of deformity and the 
severity of the symptoms ; for although all flat feet are weak feet yet 
all weak feet are not necessarily painful feet. Pain is not caused be- 
cause the foot is flat ; it is a symptom of progressive deformity, of 



512 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



strain and injury to the joints ; it shows that the foot is becoming flat 
or it is a symptom of injury that the weak or flat foot has received. 
The progress of the deformity may be temporarily or permanently 
checked at any stage, either by a removal of the exciting cause or be- 
cause of the resistance of the tissues ; then the pain ceases. On the 
other hand, this stability may not be attained until the entire sole of 
the foot rests upon the ground, and even then the patient may suffer 
from discomfort and pain. 

This conception of the foot as a machine, of which grades of efficiency 
may be recognized, has a great advantage since it enables one to per- 
ceive wherein a foot is weak even though the weakness causes no 
symptoms whatever. Thus one is enabled to prevent deformity by 
teaching the patient to avoid the extra strain that improper attitudes 
entail, and to strengthen the muscles on whose ability its integrity de- 
pends. Finally from this standpoint one may better appreciate the 
weakness and deformity that is often the direct result of improper 
shoes, a subject that will receive more extended consideration elsewhere. 

Statistics. — A brief analysis of a thousand cases of so-called flat foot 
treated at the Hospital for the Kuptured and Crippled will represent 
fairly the points of general interest in this class of cases. 

The Age and Sex of the Patients. 



Age. 

Ten years or less 

Ten to fifteen 

Fifteen to twenty 

Twenty to twenty-five 
Twenty -five to thirty. 
More than thirty 



Males. 


Females. 


68 


30 


112 


87 


144 


83 


94 


53 


68 


41 


132 


88 


618 


382 



Total. 



98 
199 
227 
147 
109 
220 



1,000 



Foot affected : right, 133 ; left, 138 ; both, 729. 



In fifty-eight cases the cause of the disability appeared to be injury, 
and in sixty-five instances it was, apparently, due to rheumatism or to 
rheumatoid arthritis. The symptoms usually appear first in one foot, 
and as a rule, they are at all times more marked on one side. Of five 
hundred and sixty-nine instances, in which the duration of symptoms 
was recorded, it was six months or less in four hundred and nine. 

The age of the patients is of interest as bearing on the question of 
prognosis. Four hundred and twenty-six were between ten and twenty 
years of age, and seven hundred and eighty were less than thirty. 

Hospital statistics cannot adequately represent the subject of the 
weak foot, for as a rule, it was because of disability and pain, not for 
the deformity or for the milder type of symptoms, that these patients 
applied for treatment. In the larger proportion muscular spasm and 
rigidity were present, in two hundred and thirty-four cases to such a 
degree that forcible over-correction was advised, an operation rarely 
necessary in private practice. 



SYMPTOMS. 513 

It is in childhood that the prevention of subsequent weakness and 
deformity is of the first importance, yet but ninety-eight children of 
ten years of age or less are recorded, and of these a large proportion 
were brought, not for weakness or deformity, but for treatment of the 
symptomatic in-toeing. 

Symptoms. — As has been stated, the symptoms of the weak foot, 
although similar in type, vary in severity according to the local con- 
dition and the disturbance of function, the work to be performed, and 
the susceptibility of the individual. The earliest symptom is usually 
a sensation of weakness ; the patient begins to recognize as familiar, a 
feeling of discomfort, of tire and strain about the inner side of the foot 
and ankle ; sometimes after long standing, a dull ache in the calf of the 
leg, or pain at the knee, hip or in the lumbar region, symptoms more 
common in women than in men; or after over-exertion a momentary sharp 
pain radiating from the point of weakness, thus the patient often dates the 
history of his trouble from a long walk. After a time the patient may 
become aware that he is accommodating his habits to his feet ; he rides 
when he once walked, he sits when he once stood, he no longer runs 
up or down stairs or jumps off the street car. His feet have lost their 
spring as he expresses it, which means that the foot is no longer sup- 
ported and controlled by muscular activity and is no longer used as a 
lever. Not infrequently, early symptoms are pain and tenderness at 
the center of the heel, explained in part by the jarring heel walk which 
is always assumed when the foot is weak, and in part by the strain 
upon the attachments of the deep plantar ligaments. The patient may 
complain that he cannot buy comfortable shoes ; the reason is that the 
weak foot under use is changed in shape, so that the shoe that was 
comfortable in the morning compresses the foot painfully at night ; 
thus increasing discomfort from corns, bunions, painful great toe joints, 
and deformities of the toes is experienced. Coldness and numbness, 
congestion and increased perspiration, caused by the impaired circula- 
tion and weakness, are common symptoms in this class of cases. 
Actual pain is, as a rule, felt only when the foot is in use ; it ceases 
under temporary rest or relief from disproportionate work, and it is 
this remittance of symptoms, together with the fact that the discom- 
fort is usually more marked in damp weather, that leads so often to 
the mistaken diagnosis of rheumatism. The foot is weak and vulner- 
able ; the patient recognizes the fact that he has what he speaks of as 
a weak ankle, or sprain, or gout, or rheumatism, but if he has accom- 
modated himself to the weakness, but little discomfort is experienced. 
In many instances such relief or accommodation is impossible, and it 
is therefore among the working class that one oftener sees the frank 
and rapid development of the disability and deformity. The range of 
motion becomes more and more restricted ; the habitual attitude, at 
first exaggerated to deformity only under the influence of the weight 
of the body, remains as a permanent displacement of the bones. The 
weak and dislocated foot is subjected to constant injury, to what may 
be likened to a succession of slight sprains, so that local congestion, 
33 



514 DISABILITIES AND DEFORMITIES OF THE FOOT. 

tenderness and swelling may appear together with muscular spasm, 
rigidity, and pain on passive motion. Because of this rigidity of the 
foot, which has lost the power to accommodate itself to inequalities of 
the surface, the patient dreads to cross a rough pavement, for every 
misstep is a source of pain. Another symptom, the discomfort felt in 
changing from a position of rest to activity, which is usually present 
in slight degree at every stage, now becomes more prominent. The 
patient, after sitting or on rising in the morning, is unable to walk, 
but staggers and limps for several minutes, a symptom explained by 
the fact, that when the foot is at rest, there is a partial reposition of 
the displaced bones, which must be again forced into the deformed 
posture that has become habitual. The local tenderness and muscular 
spasm are increased by use, so that the patient may have difficulty in 
removing the shoe at night and the symptoms relieved by the rest of 
Sunday become progressively worse during the week. The pain and 
discomfort are more general in character, and are often referred to the 
dorsum of the foot, representing muscular rigidity and tension, and to 
the ankle where the external malleolus is grinding out a facet in the 
projecting os calcis. The patient may now complain of discomfort in 
the feet and cramps in the legs, even when in bed, and the appearance 
of weakness, awkwardness, and depression of spirits may be so notice- 
able that the case is sometimes mistaken for serious disease of the 
nervous system. 

The appearance of such a foot has already been described, and the 
effect of the deformity on its function should be evident. The gait is 
slouchy and cloddy, what has been spoken of as the pedestal walk : 
the feet are simply pushed by one another, in the attitude of eversion, 
the knees are slightly flexed and the weight is borne entirely upon the 
posterior segment of the foot. The muscles have atrophied, the foot 
is cold and congested from its continued inactivity and it usually is 
bathed in perspiration. A certain range of motion remains at the 
ankle joint but adduction is absolutely restricted by the shortened and 
spasmodically contracted muscles on the outer and upper surface. 
This type represents, of course, only the severe variety that is more 
likely to be seen in hospital than in private practice ; and it would 
seem, were it not for the evidence to the contrary which the histories 
of the patients present, that the nature of the trouble must be recog- 
nized at a glance. But in the milder and earlier cases the diagnosis is 
not always so easily made. 

Diagnosis. — In all cases of suspected weakness of the foot, a 
thorough and orderly examination should be made, not only of its ap- 
pearance, but also of its functional ability and of the manner in which 
it is used. Such an examination is not merely for the purpose of diag- 
nosis, which is usually apparent, but in order that the amount and 
character of the temporary or permanent changes in structure and func- 
tion may be properly estimated. 

Attitudes.— One begins the examination by noting the manner of 
standing and walking. The heel walk, the exaggerated turning out of 



DIAGNOSIS. 515 

the feet, the slouchy gait in which the leg is never completely extended, 
in which the power of the calf muscle is not applied, and in which 
the essential postures of the foot are disused, are all elements of weak- 
ness that should be corrected whether they cause symptoms or not. 

Distribution of Weight and Strain.— The distribution of the 
weight of the body and the habitual use of the foot are often made evi- 
dent by examining the worn shoe. If it is bulged inward at the arch 
or worn away on the inner side of the sole, it shows weakness. (Fig. 
360.) The same observations are then made on the bare feet, particu- 
lar attention being paid to the line of strain or leverage ; thus a line 
drawn down the crest of the tibia from the center of the patella, con- 
tinued over the foot, should meet the interval between the second and 
third toes ; if it falls over or inside the great toe, it shows that the foot 
is working at a disadvantage. (Fig. 352.) 

Contour. — The contour of the foot should then be examined ; its 
internal border should curve slightly outward, so that if the feet are 
placed side by side with the toes and heels in apposition, a slight inter- 
val remains between them ; if this slight concavity is replaced by a 
noticeable convexity, when weight is borne the foot is weak. (Fig. 
357.) This change in contour is the earliest and sometimes the only 
evidence of deformity. The arch of the foot, properly protected by 
the muscles and by a proper attitude, sinks but slightly under weight ; 
there is a slight elasticity only, as the strain is thrown more to the 
inner side of the median line, and if the depression is marked it shows 
weakness. 

Bearing Surface. — The exact amount of bearing surface may be 
shown by an imprint upon carbon paper or by smearing the sole with 
vaseline, then as the patient stands upon a sheet of white paper the outline 
of the foot should be traced, so that the relative size of the imprint to 
that of the foot may be shown and compared with the normal standard. 

Another method is that suggested by Lovett. The patient, stands 
upon a square of plate glass fixed in a table, so that by means of a 
mirror beneath, the bearing surface may be examined under different 
degrees of pressure and in different attitudes. (Fig. 361.) 

The Range of Motion. — The balance of the foot, as shown by the 
range of motion, is next to be tested, for its limitation is one of the 
earliest signs of improper attitudes and of weakness. This range of 
motion varies somewhat within normal limits ; it is usually greater in 
childhood than in adult life, greater in the slender than in the massive 
foot, and greater in the foot used properly than in one that is not. The 
first test is applied to simple dorsal and plantar flexion ; the leg must 
be fully extended at the knee, the line of strain must be in its normal 
relation, so that the foot may be neither aclducted nor abducted and the 
observation must be made on its outer border. 

In this position the patient should be able to flex the foot from ten 
to twenty degrees less than the right angle, and to extend it from forty 
to fifty degrees beyond the right angle, the range of motion being from 
fifty to sixty degrees. (Figs. 336, 337.) 



518 DISABILITIES AND DEFORMITIES OF THE FOOT. 

By far the most important test is that of the power of adduction or 
inversion of the foot, the test of the medio-tarsal and sub-astragaloid 
joints, a motion in which the os calcis is drawn forward and inward 
under the astragalus, while the forefoot is flexed about its head. With 
the leg extended and the patella pointing forward the foot is turned 
inward as far as possible ; the elevation of its inner border or supina- 
tion and the turning in of the heel are well illustrated in Figure 
338 ; the actual range of adduction is somewhat difficult to measure, 
but it is about thirty degrees. Even the mild and early cases of weak 
foot usually show some limitation of this most important motion and 
in many instances it is completely lost, the patient turning the entire 
leg in the effort to adduct the foot. The less important motion of ab- 
duction may be tested also (Fig. 339) ; its range is about half that of 
adduction, so also the range of supination or inversion of the sole is 
nearly twice as great as that of pronation or eversion of the sole. In 
other words the internal border of the foot can be raised twice as far 
from the floor, as can the external border. The range of passive mo- 
tion is then tested by pushing the foot in all directions. The range 
of dorsal flexion is from five to ten degrees beyond that of voluntary 
motion, while passive extension, so far as it applies to the ankle joint, 
is about the same as the voluntary, although the forefoot may be still 
farther bent downward at the medio-tarsal joint. The limit of passive 
adduction is considerably beyond that of voluntary inversion. 1 

Passive motion serves several purposes ; contrasted with the range 
of voluntary motion it shows the habitual use of the foot, since the 
motion least used is most limited. It also makes evident the slight 
restriction of motion and the presence of local tenderness, which, even 
in early cases, are usually present. Thus, if pressure is made just in 
front of and below the internal malleolus, at the astragalo-scaphoid 
junction, and at the same time the foot is quickly adducted, the patient 
will complain of pain at the point of pressure and of a feeling of con- 
striction and tension about the dorsum of the foot, before the normal 
limit of motion is reached. When the foot is dorsi-flexed the plantar 
fascia is put upon the stretch, and its condition may be noted, for a 
contracted and sensitive plantar fascia may cause symptoms of discom- 
fort, that may induce improper attitudes and thus predispose to further 
disability. 

Varieties of the Weak Foot. — This mode of examination will 
demonstrate the disability and permanent change in the machine, 
which must be overcome before a cure can be accomplished. By it 
one will learn to recognize several grades of weak foot. 

1. The normal foot improperly used, as shown by the manner of 
standing and walking. 

1 As adduction and supination and abduction and pronation are always combined, 
one term is used to signify the movement inward or outward ; thus, supination means 
adduction, abduction implies pronation. A fixed attitude of adduction and supination 
is called varus, a fixed attitude of abduction and pronation is called valgus. Varus 
and valgus signify, therefore, deformity. Thus the term valgus although it may be 
properly applied to designate the deformity of weak foot is usually reserved for the 
more extreme distortion of talipes. (See Figs. 338 and 339. ) 



EXTREME TYPES OF WEAK FOOT. 517 

2. The foot, which because of laxity of ligaments or insufficient 
muscular support, is forced by the weight of the body into an attitude 
of deformity ; that is, in which the foot under weight falls into an 
abnormal attitude of abduction in its relation to the leg, as evidenced 
by the inward projection of its inner border and by the overhanging 
internal malleolus, showing that the leg has been displaced inward on 
the foot. As a rule, there is sufficient laxity of ligaments to allow a 
depression of the arch, as shown by the imprint, but in other instances, 
although the arch seems lower because of the characteristic attitude, in 
which the leg, as it were overhangs the foot, yet the imprint shows 
that there is no increase in the area of bearing surface. Indeed this 
may be even smaller than normal ; thus an individual may suffer 
from so-called flat foot whose arch is actually exaggerated. 

3. The weak foot, which shows typical deformity under use and in 
which the range of voluntary motion is somewhat limited, particularly 
in the direction of plantar flexion and adduction. Forced motion causes 
discomfort and pain, indicating a certain permanent accommodative 
change in structure, which is not apparent when the foot is not in use. 

4. The foot which presents typical and permanent deformity, whether 
it is in use or not, and in which the range of both voluntary and pas- 
sive motion is much restricted. In all of these varieties, however, the 
improper functional use of the foot, in the loss of active leverage, is 
very evident when the patient walks. 

Limitation of Motion and Muscular Spasm. — Limitation of 
motion is caused by the accommodative changes in structure to the 
habitual postures or to the deformity. These are first evident in the 
muscles and ligaments and finally in the articular surfaces of the bones. 
Added to this underlying limitation of motion, there is usually a certain 
amount of muscular spasm, which varies in degree with the local con- 
gestion, irritation and inflammation of the joints and tissues. In the 
quiescent flat foot it may be absent but on renewed injury or over- work 
of the weak structure, it again appears. It depends also upon the 
irritable condition of the over- worked and contracted abductor mus- 
cles, practically the only group which retains functional power ; thus 
the spasm, as has been stated in describing the severe and painful type 
of weak foot, is greater after the day's use and relaxes somewhat 
during the night. The degree of muscular spasm and rigidity corre- 
sponds with the intensity of the symptoms, but by no means with the 
depression of the arch or with the duration of the deformity. 

Extreme Types of Weak Foot. 1. Persistent Abduction. — In 
one type of rigid foot the foot is twisted outward and upward. It- 
may be pronated to such an extent that practically the weight is borne 
upon the heel and the ball of the great toe. In such instances the 
astragalus, although rotated inward upon the pronated os calcis, is, of 
course, not plantar flexed nor is the anterior extremity of the os calcis 
depressed. The entire foot is simply held in an attitude of extreme 
abduction and dorsal flexion, by the spasm and contraction of the flexors 
and abductors, so that the leg must be bent at the knee and inclined 



518 



DISABILITIES AND DEFORMITIES OF THE FOOT 



Fig. 358. 



forward to bring the sole to the ground. Such extreme cases are un- 
common. They are often the direct result of injury, so-called chronic 
sprain, and when the deformity is reduced the arch will be found to be 
exaggerated in depth. Less extreme types of this class are often seen 
and they serve to emphasize the statement that the most important dis- 
ability of the weak foot is due to the change from the normal relation 
between the leg and the foot and not to the depression of the arch, 
which is in most instances a secondary deformity. 

2. Pes Plaxus. — As has been stated already, and as is well known, 
there is a type of painless flat foot sometimes called pes planus in 

which the flatness of the foot is 
more noticeable than the other 
components of the deformity 
that have been described. This 
is probably the result of in- 
herited laxity of ligaments or 
of rhachitis or other form of 
acquired weakness in early life, 
so that a normal arch was never 
present. Such a foot controlled 
by normal muscles, may be 
strong and efficient but it is 
nevertheless deformed, and it is 
doubtful if its possessor ever 
could attain the grace and elas- 
ticity of gait possible under nor- 
mal conditions. It is said also, 
that a low arch is normal in 
certain races, for example the 
negro, but it is certain that the 
American negro is not exempt 
from the pain and disability 
incidental to the broken-down 
foot, whether his arch was 
originally low or not. 
It is evident, of course, that the breaking down of a properly 
shaped foot, provided with normal ligaments, will be attended by 
greater pain and greater disability than of one in which the arch was 
originally low and of which the ligaments were weak, because it 
is during the progression of the deformity and particularly in its 
early stages, that such symptoms are most prominent. When the 
bones of the arch rest upon the ground or when final stability has 
become assured, pain may cease, and permanent accommodation to 
the new conditions may increase the ability of the deformed mem- 
ber. Such an outcome might be quickly accomplished in the foot 
originally flat, while in the other instance, the symptoms although 
remitting from time to time, might continue during the life of the 
sufferer. 




Weak feet and slight knock knees. 



WEAK FOOT IN CHILDHOOD. 



519 



Weak Foot in Childhood. 

There can be no doubt that in many instances, the origin of the 
weak foot may be traced to early childhood. Certainly, deformities 
and improper attitudes are very common at this period, and it is much 
more likely that they are ingrown than outgrown. Actual pain from 
the weak foot is rare at this age. The child may complain of fatigue 
and may be weak and awkward, but it is usually because of the very 
evident deformity, rather than because of symptoms, that advice is 
asked. In these cases, as in every case, the habitual attitudes and use 
of the feet are of the first importance. 

Out and In Toeing as Symptoms of the Weak Foot in Child- 
hood. — One of the most frequent of the improper postures is that of 
exaggerated outward rotation of the feet, which is not only an ungrace- 
ful attitude, but a direct cause of weakness as well. The opposite 
attitude of inward rotation, the so- 
called " pigeon-toed " walk, is most Fig. 359. 
offensive to relatives and friends, and 
it is for correction of the attitude 
that the child may be brought for 
treatment. The attitude is, in many 
instances, a sign of the weak foot, 
for on examination the bulging on 
the inner side, the inward rotation 
of the leg in its relation to the foot, 
and the flattened arch, show very 
plainly that it is the foot and not the 
attitude that requires treatment ; in 
fact, the attitude is, in this class 
of cases, really a safeguard against 
increasing deformity and it will 
correct itself when its cause is re- 
moved. Particular emphasis is laid 
upon this point, which is very gen- 
erally over-looked, because the rou- 
tine treatment of the " pigeon toes " 
in these cases might be the cause 
of direct harm. 

Weak Ankles. — " Weak ankle " is a term popularly applied to the 
weak foot of childhood, in which the foot is in a position of valgus 
when in use, so that the shoe is worn away on its inner side. Weak 
ankles are very common in very young children and are often one of 
the results of general weakness due to defective assimilation. At this 
age the foot is, in addition, usually flat (Fig. 358), but in the valgus 
or weak ankle of later years the arch is often practically normal in 
outline. 

Outgrown Joints. — In older children prominent or "outgrown" 
joints often attract the mother's attention ; the internal malleoli appear 




Congenital flat foot. Rigid deformity of 
an extreme type illustrating the component 
abduction and obliteration of the arch. 



520 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



prominent because of the position of valgus, or because of the eversion 
of the feet the malleoli may strike against one another, "interfere," 
and thus there may be an actual hypertrophy of the projecting bones 
from local irritation. 

Another type is the long slender foot in which the scaphoid bone is 
prominent because of the strain and pressure put upon it by the im- 
proper attitudes ; its position is often shown by the point of wear in 
the leather of the shoe. (Fig. 357.) 

In the weak foot of childhood, although restriction of voluntary and 
passive motion may be present, there are, as a rule, but little local ten- 
derness and muscular spasm, and as has been said, but little actual 
pain ; thus it differs greatly from the adult type, for the reason that 
the weak foot in childhood has not been subjected to the strain of con- 
stant occupation or to the burden of the increased weight of the body. 
There is another important difference also ; the foot of the adult is 

obliged to bear greater strain 
Fig. 360. than any other part, and al- 

though normal in structure it 
may be over-strained, so that 
in many or in most instances 
the weakness of the foot may 
be the only disability. But in 
childhood, when such exciting 
causes are absent, a weak foot 
is very often a local indication 
of general weakness and loss 
of tone. 

Geneeal Weakness. — 
The direct effects of the weak 
and painful foot have been de- 
scribed in detail. It must be 
borne in mind that the feet are 
the foundation of the body, and 
that an insecure foundation affects the entire mechanism. General 
functional weakness and awkwardness, the flat chest, round shoulders or 
other curvatures of the spine, are often observed as accompaniments or 
effects of weak feet. Thus, as a rule, the systematic treatment of any 
form of postural weakness must include the treatment of the feet as well. 
Recapitulation. — The disability and deformity of the weak or so- 
called flat foot are caused by a disproportion between the strength of 
the foot and the weight and strain to which it is subjected. 

The foot may be weakened by injury or disease ; it may be over- 
burdened by the body-weight, or over-strained by laborious occupation, 
or the broken-down foot may be simply one indication of general bodily 
weakness. It is unnecessary to enumerate all the various factors that 
singly or combined lead to this disability. It may be stated, however, 
that the weak foot is in many, or most, instances the only disability 
that demands treatment. Its most constant predisposing causes are 




Flat foot, extreme deformity in childhood. 



TREATMENT. 521 

improper shoes, and the mechanical disadvantages to which it is sub- 
jected by the assumption of improper attitudes. 

All weak or flat feet are mechanically weak, but all weak feet are 
by no means painful feet. Pain, the symptom of over-strain or injury, 
bears no definite relation to the degree of deformity. 

In certain instances, exaggeration of the arch may be combined with 
persistent abduction of the foot ; in others, the flattening of the arch 
may be the most noticeable deformity, but in most cases, the two are 
combined in varying degree. And as each deformity is an evidence of 
weakness, it seems hardly necessary to make a radical distinction be- 
tween the two, except as regards prognosis. For the abducted foot in 
which the arch is intact is almost always an acquired deformity of 
short duration, whereas in the case of the foot in which the arch is 
obliterated the deformity usually dates from early childhood and it is, 
therefore, much less amenable to treatment as far as perfect cure is 
concerned. 

Treatment. — The principles of the treatment which leads to the 
permanent cure of the weak and deformed foot are very simple, but 
the application varies somewhat according to the grade and duration 
of the deformity. The object of treatment is to so change the weak 
foot that it may conform, not only in contour but in habitual attitudes 
and in power of voluntary motion to those of the normal foot, because 
complete cure is impossible unless normal function is regained. The 
first step must be, therefore, to make passive motion free and painless 
to the normal limit. In other words the obstructions to the motion 
of the machine must be removed before the power can be properly ap- 
plied ; for the increase of muscular strength and ability, on which 
ultimate cure depends, is not possible while motion is restrained by de- 
formity or by pain or by adhesions or contractions. 

The weak foot, because of inefficient ligaments and muscles unable 
to hold itself in proper position, must be supported, in many instances, 
until regenerative changes have taken place in its structure.' Such 
support is necessary to retain the joints in proper position, and to hold 
the weight and the strain in proper relation to the foot, otherwise nor- 
mal motion is impossible. When these essentials are provided, the 
patient may cure himself by the proper functional use of the foot, 
and by the avoidance of attitudes that place it at a disadvantage. 

It may be well to describe, first, the treatment that must be applied 
to all classes of weak foot in which a cure is to be attempted, and which 
by itself is sufficient in the milder types, before calling attention to the 
modifications that may be necessary in special cases. 

The Shoe. — In practically all cases it will be necessary to provide 
the patient with a proper shoe, for the shoe is usually the direct cause 
of the minor deformities, and indirectly, in many instances, of more 
serious disability. Indeed most of the deformities and disabilities of 
the foot are incidental to civilization and are therefore confined to the 
shoe-wearing people. The direct effect of the ordinary shoe is to lessen 
the size and balancing power of the fulcrum by cramping the toes 



522 



DISABILITIES AND DEFORMITIES OF THE FOOT 



Fig. 361. 



together while the high heel throws more strain upon the arch and the 
ankle. Indirectly it causes deformities, corns, bunions and the like, 
which serve to make active movement or leverage painful, so that it is 
replaced by the passive attitude. 

The proper shoe should contain sufficient space for the independent 
movements of the toes. This motion is illustrated in the walk of the 
barefoot child. As the weight falls on the foot the toes expand, and 
as the body is raised on the foot they contract. The important lever- 
age action of the great toe and the support 
afforded by it to the arch of the foot have 
already been mentioned. The shape of the 
sole should correspond to the shape of the 
foot and the heel should be broad and low. 
(Fig. 361.) 

The prevention of distorted toes and the 
discomforts that result from the abuse of 
the foot is of great importance in child- 
hood, but unfortunately, little children are 
often seen wearing shoes of the shape 
usually assumed at years of discretion. In 
this regard, girls suffer more than boys as 
women do more than men. The girl who 
may have worn comparatively harmless 
shoes until the age of ten years or there- 
abouts, changes suddenly to the high heel 
and narrow sole, and the process of distor- 
tion begins, the amount of distortion and 
the degree of discomfort depending on the 
amount of work required of the foot. 
Wide soles without heels should be worn 
as long as possible by children because of 
the greater stability and because the high 
heel limits the necessity for, and therefore 
the use of, the entire range of motion of 
the foot and ankle. 

Kaising the Inner Border of the 
Shoe. — A simple expedient in the treat- 
ment of the weak foot and an aid in bal- 
ancing it properly, is to make the inner 
border of the sole and heel of the shoe 
slightly thicker in order to throw the weight toward the outer side of 
the foot. This is of especial importance in the treatment of the 
slighter degrees of Avhat is known as weak ankle but it is always of 
service in the treatment of any grade of weak foot. 

Attitudes. — When the patient stands, properly balanced in the 
proper shoe, his attention is called to the three elements of weakness. 
He is instructed to guard against valgus (Fig. 351) by throwing the 
weight on the outer side of the foot (Fig. 352) and to guard against 




The proper relation of the sole to 
the shape of the foot. A, outline of 
sole ; B, outline of foot ; C, imprint 
of foot. 



SUPPORT. 523 

abduction by holding the feet parallel with one another in walking 
(Fig. 334) ; the significance of the bulging on the inner side of the foot 
is pointed out to him, how this may be prevented by the avoidance of 
the postures just indicated and by aiding the arch by the power of the 
great toe. The importance of leverage is shown him, that he must try 
to press down the sole of the shoe with his toes and employ the active 
lift of the calf muscles by fully extending the leg and raising the body 
on the foot from time to time. (Fig. 334.) Finally, he must avoid 
long continuance in one position, especially the passive posture, which 
simulates the attitude and deformity of flat foot. In short he must 
be instructed in the mechanics of the foot and taught how the weak 
foot may be protected as well as strengthened. 

Exercises. — It is important, also, to show the patient the normal 
range of motion of the foot, motion which, if restricted, must be re- 
gained by voluntary and passive exercise. Voluntary exercise should 
be devoted to strengthening the adductors and plantar flexors ; thus 
the foot should be adducted and supinated (Fig. 338) over and over 
again at every opportunity. Tip-toe exercises are especially useful ; 
the patient, holding the feet parallel, raises the body on the toes twenty 
to one hundred times, resting in the intervals on the outer border of 
the feet. The best of all exercises is, however, the proper walk, in 
Avhich the leverage power of the foot is employed and in which it 
passes through the proper alternation of postures. (Fig. 334.) Treat- 
ment by massage and special gymnastic exercises is of course of bene- 
fit, if the patient can command it, although by no means essential to 
the cure. 

Support. — In many instances the simple treatment that has been 
outlined is all that is required and the symptoms of tire and strain 
are quickly relieved, but in the more advanced type of disability the 
patient is not able to prevent deformity voluntarily, consequently a 
support is necessary to hold the foot in proper position and to relieve 
discomfort. It is usually necessary in the treatment of the we*ak foot 
of childhood, because one cannot command the aid of the patient. 

In selecting a support for the weak foot the nature of the deformity 
that is to be prevented must be borne in mind ; that the acquired flat 
foot, for example, is not a direct breaking down of the arch, as is 
usually taught, but a lateral deviation and sinking — a compound de- 
formity, as has been already described. (Fig. 351.) Thus a brace, to 
be efficient, must hold the foot laterally as well as support the arch. 
But it must not prevent the normal motions of the foot, and thus inter- 
fere with the increase of muscular strength and ability, on which ulti- 
mate cure depends. 

The supports that have been ordinarily used for flat foot do not ful- 
fil the conditions; the pads and springs placed beneath the arch are 
intended to support it by direct pressure without regard to the valgus 
or the abduction ; they are usually ill-fitting and are often of such 
length and shape as to splint the foot and thus to restrict its motion. 
Leg braces which control the valgus do not often hold the foot accu- 



524 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



rately, and their weight and unsightliness are fatal objections to their 
use in the early cases, in which prevention of subsequent deformity is 
of such importance. 

A brace should never be applied to a deformed and rigid foot because 
it is unable to shape itself to the support ; the spasm and rigidity must 
be first relieved by preliminary treatment, as will presently be de- 
scribed. 

The Construction of the Brace. — To properly construct a brace to 
meet these conditions, it is necessary to provide the mechanic with a 
plaster cast of the foot, taken in the attitude in which one wishes to 
support it. Such a model may be easily and quickly made in the fol- 
lowing manner. 

The Plaster Cast. — Seat the patient in a chair ; in front of him 
place another chair of equal height ; on it lay a thick pad of cotton 
batting and cover it with a square of cotton cloth. Put about a 
quart of cold water into a basin and sprinkle plaster of Paris on the 

Fig. 362. 




The attitude in which the plaster cast should be taken. In the reproduction, the chair upon which 
the foot is resting, has been removed. 

surface until it does not readily sink to the bottom ; then stir. 
When the mixture is of the consistence of very thick cream pour it 
upon the cloth. The patient's knee is then flexed, and the outer side 
of the foot, previously smeared lightly with vaseline, is allowed to sink 
into the plaster and, the borders of the cloth being raised, the plaster 
is pressed against the foot until rather more than half is covered. 



THE BRACE. 



525 




A, the astragalo-scaphoid joint. The internal flange of the 
brace should rise well above all the prominent bones to a point 
about half an inch below the malleolus. 



The foot should be at a right angle with the leg and the sole should 
be in the plane perpendicular to the seat of the chair. (Fig. 362.) 
As soon as the plaster is hard its upper surface is coated with vaseline 
and the remainder of the foot is covered with plaster ; the two halves 
are then removed, smeared lightly with vaseline and bandaged to- 
gether. The interior is dampened with soapsuds and it is then filled 
with the plaster cream. 

In a few moments the Fig. 363. 

plaster shell may be re- 
moved, and one has a re- 
production of the foot, 
which, when properly 
made, should stand up- 
right without inclination 
to one side or the other. 
In many instances it 
will be of advantage to 
deepen in the plaster 
model the inner and 
outer segments of the 
arch, in order that the 
arch of the brace may be 

slightly exaggerated, especially at the heel, so that the depression of 
the anterior extremity of the os calcis may be prevented. 

The Brace. — Upon the model the outline of the brace is drawn as 
illustrated in the diagrams. The best sheet steel, 18 to 20 gauge, cut 
after the pattern is moulded upon it and tempered, so that, as it is ap- 
plied for the purpose of preventing deformity, it may be practically 

unyielding to the weight of the 
Fig. 364. body. 

It will be noticed that the 

brace clasps the weak paft of the 

foot and holds it together ; the 

broad internal upright portion 

(Fig. 363) covers and protects 

the astragalo-scaphoid junction, 

rising well above the scaphoid ; 

the external arm covers the 

calcaneo-cuboid junction and the 

outer aspect of the foot to a 

height sufficient to hold the foot 

securely. (Fig. 364.) The sole 

part provides a firm, comfortable support, yet, reaching only from the 

center of the heel to just behind the ball of the great toe, it does not 

restrain the normal motions of the foot. (Fig. 365.) 

The brace may be nickel plated and japanned, which makes a smooth 
finish, or tin plated, or galvanized, which makes a more durable cov- 
ering. It may be covered with leather, or an inner sole may be placed 




B, the calcaneo-cuboid junction. The external 
flange extends from the center of the heel to a point 
slightly behind the base of the fifth metatarsal bone. 



526 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



Fig. 365. 




on its upper surface ; but this is not usually necessary. As it is fitted 
to the foot, it finds and holds its own place in the shoe, so that no at- 
tachment is required ; thus it may be changed from one shoe to another. 
Not only does it hold the foot laterally and from beneath, but there is 
an element of suggestiveness in the slight leverage 
action which is very important. 

The Positive Action of a Proper Brace. — The 
patient, instructed to throw his weight upon the 
outer side of the foot and wearing the shoe which 
has been tilted in the same direction by thickening 
the inner border of the sole and heel, presses down 
the external arm and thus lifts the internal flange 
against the inner side of the foot, which is instinc- 
tively drawn away from the pressure and thus 
toward the normal contour ; he no longer everts or 
turns the feet outward in walking, and he is not 
likely to assume the passive attitude, because of the 
suggestive lateral pressure of the support ; thus it 
becomes a positive aid in the physiological cure. 

The shape of the brace, in general like that of 
the diagram, is modified in certain cases ; for in- 
stance, the entire internal aspect of the foot may be 
weak and must be covered by the internal flange. 
In very heavy subjects the sole portion must be 
made larger although this is a detriment, as it les- 
sens the leverage action ; other slight modifica- 
tions may be necessary in special cases. If any portion of the rim of 
the plate causes discomfort, the edge may be turned away slightly at 
the point of pressure by a wrench. After a few days the patient no 
longer notices the presence of the brace, and as its presence in the shoe 
is not evident, it may be worn indefinitely. 

It is usually necessary for from three months to a year or longer, 
according to the condition of the patient and the strain to which the feet 
are subjected. The brace, properly made and adjusted under the proper 
conditions, causes no more pressure or discomfort than a well made 
shoe, for its principle is quite different from that of the ordinary sup- 
ports that are in common use, to which this objection has been made. 
This brace supports the arch primarily by preventing abduction, con- 
sequently its pressure is first felt upon the lateral aspect of the foot, a 
pressure that the patient can relieve by improving his attitude. The 
brace should afford support when necessary, and at all times suggest 
and enforce a proper attitude ; it is, however, but one of the essential 
factors in the general scheme of treatment. 

In the treatment of children, the foot should be moved in all direc- 
tions but particularly in dorsal flexion and adduction to the full limit 
at morning and at night, until the child has regained the normal 
muscular power and ability. Special gymnastics and massage are al- 
ways desirable and they may be necessary in certain cases. Bicycling 



C, the great-toe joint 
D, the center of the heel 



THE RIGID WEAK FOOT. 527 

may be cited as one of the best, and roller skating as one of the worst 
exercises for the weak foot. A year is about the time required for a 
cure of the weak foot in childhood, although attention to the shoes and 
to the attitudes must be continued indefinitely. 

The Rigid Weak Foot. 

One may now contrast with these mild types of weakness that have 
been described, those cases of extreme deformity in which the symptoms 
are disabling and in which the foot is rigidly held in the deformed 
position by muscular spasm and by secondary changes in its structure. 
Such cases, often considered hopeless as regards a cure or even relief, 
are in reality the most satisfactory from the remedial standpoint, and 
in no other type of painful deformity can so much be accomplished by 
rational treatment as in this class. The deformity must be considered 
as a dislocation in which the astragalus has slipped downward and in- 
ward from oif the os calcis, which in turn is tipped downward and in- 
ward and into a position of valgus. The remainder of the foot is 
turned outward, so that the relation of the leg and the forefoot is entirely 
changed ; in fact the forefoot is almost entirely disused. (Fig. 366.) 

Corresponding to the duration of the disability, one finds accommo- 
dative changes in the soft parts and in the bones, but such changes are 
by no means as marked as those recorded in the reports of autopsies 
which have been made in cases of advanced and irremediable deformity. 
In fact, by far the greater number of patients are young adults in 
whom the extreme deformity is of comparatively short duration, and 
in whom complete cure is possible. 

In the treatment of such a condition, one must first reduce the dis- 
location and overcome the obstacles that contracted muscles and liga- 
ments may offer to free and normal motion ; then rest must be assured 
to the injured and congested parts in order to relieve the patient from 
the pain from which he has suffered so long. 

Forcible Over-correction. — By far the most effective treatment is 
forcible over-correction of the deformity, under anaesthesia. When 
the patient is under the influence of the anaesthetic the muscular spasm 
relaxes, and it will be seen that this accounts for about half of the re- 
striction of motion, the remainder being caused by the adaptive changes 
that have been mentioned. One now endeavors to overcome this resi- 
dual obstruction ; and to assure the patient against a relapse, by fixing 
the foot in the position of extreme adduction and supination, the atti- 
tude directly opposed to that which has become habitual. 

This is the object of forcible over-correction as the first step in the 
systematic repair of the disabled mechanism ; its principle must not be 
confounded with forcible correction carried out with the object of 
simply remoulding the arch of the foot, or in which the simple cor- 
rection of the deformity is the object in view. 

One first extends the foot forcibly, then flexes it to the normal limit, 
then abducts and adducts, the different motions being carried out over 



528 DISABILITIES AND DEFORMITIES OF THE FOOT. 

and over until the rigid foot has become perfectly flexible. In cases 
of long standing it is often necessary to draw the patient to the end of 
the table, so that the foot may be taken between the knees, in order to 
supply the required force by the thigh muscles. This forcible manipu- 
lation is accompanied by the audible breaking of adhesions, and the 
complete disappearance of the deformity. In certain instances it will be 
necessary to divide the tendo Achillis when, for example, the range of 
dorsal flexion is limited by resistant accommodative shortening of the 
calf muscles, or when there has been very great pain and tenderness at 
the medio-tarsal joint, and it is desired to remove the strain of lever- 
age completely ; traumatic cases come especially under this head. 
Tenotomy has one great advantage, it necessitates longer fixation in 
the plaster bandage, and gives the patient the benefit of rest, and the 

Fig. 366. Fig. 367. 




The deformed foot before The over-corrected foot, 

operation. A, the projecton of showing the reversal of the 
the displaced astragalus and lines of displacement. (See 
scaphoid ; B, the inner malleo- Fig. 368.) 
lus ; C, the mediotarsal joint, 
showing the outward displace- 
ment before, the inward rota- 
tion behind, this point. 

opportunity for prolonged after-treatment. When the passive range 
of motion has been regained, the foot is turned downward, then inward 
and upward into the position of extreme varus. By this manipulation 
the os calcis is drawn under the astragalus and thrown into the supi- 
nated position, and the scaphoid is flexed about and under the head of 
the astragalus, which is then lifted to the limit of normal flexion. The 
attempt is always made to bring the extreme outer border of the in- 
verted foot up to a right angle with the leg, which is the limit of nor- 
mal flexion in this attitude. The foot, thickly padded with cotton, is 
then fixed in this posture of club foot by a firm plaster of Paris band- 
age extending to the knee. (Fig. 368.) Surprisingly little discom- 
fort, considering the force that it is sometimes necessary to apply, is 
experienced after the operation. The familiar and often intense pain, 
from which the patient has suffered so long, is entirely relieved by the 



THE RIGID WEAK FOOT. 



529 



correction of the deformity ; there is often a sense of tension about the 
outer side of the ankle and dorsum of the foot, but this is not, as a rule, 
of long duration. 

Functional Use in the Over-corrected Attitude. — As soon as possible, 
often on the following day, the patient is encouraged to stand and 
walk, bearing his weight on the foot. Walking serves two purposes : 
to still further over-correct the deformity, and to accustom the patient 
to a posture entirely different from that so long assumed. Meanwhile 
the contracted tissues on the outer side become thoroughly over- 
stretched ; the weakened ligaments and muscles on the inner side are 
relaxed, and the local irritation rapidly subsides under the rest from 
the constant injury to which the foot has been subjected. 

The patient is not confined to the bed or house, although if both feet 
are in plaster bandages, crutches are of course necessary. The time 
that the feet should remain in the over-corrected position, depends 
upon the duration of the deformity and the severity of symptoms, or 
from one to six weeks, the usual time 

being about three weeks. At the end Fig. 368. 

of two weeks, or whenever the pa- 
tient can support the weight on the 
plaster bandage, without a sensation 
of discomfort, it is removed ; the 
foot is placed in the normal attitude, 
and a cast is taken for the brace. 
Immediately after this is made, the 
foot is returned to the club-foot po- 
sition and the plaster bandage is 
re-applied. When the brace is ready, 
the plaster bandage is finally re- 
moved ; the foot is now in good po- 
sition, and in many instances the 
arch is exaggerated in depth. For 
the first few days, prolonged soaking 
in hot water, or the use of the hot- 
air bath, with subsequent massage, at 
intervals during the day, will be 
found useful in overcoming the swell- 
ing and local tenderness that may re- 
main. It is always insisted that a 
new shoe of the Waukenphast pattern 
shall be obtained, the sole and heel of 
which are raised a quarter of an inch 
on the inner border, to aid in the bal- 
ancing of the weak foot. The brace is then applied, and the patient 
is never allowed to walk without its support. When the shoe is re- 
moved at night, he is instructed to turn the toes in and to bear the 
weight on the outer side of the foot until it has regained its strength ; 
in other words, the deformity is never allowed to recur. 
34 




The forcible over-correction of flat foot. The 
proper position in the plaster bandage. 



530 DISABILITIES AND DEFORMITIES OF THE FOOT 

Systematic Manipulation. — The systematic treatment is then begun 
by the surgeon and the patient, the first essential being the attainment 
of free and painless passive motion in all directions. These motions, 
which have been so long restrained by deformity, cannot be regained 
without effort, and during this critical stage, treatment must be carried 
out by the surgeon himself; if he trusts to the patient or to his friends, 
a cure is out of the question. At least once a day the full range of 
motion must be carried out to the normal limit. Three motions, ab- 
duction, flexion, and extension are usually free and painless ; but the 
fourth, that of adduction, is almost invariably resisted by the same 
quality of muscular rigidity that was present before the operation. By 
far the most effective method of overcoming this resistance is con- 
ducted as follows : the patient being seated in a chair, the surgeon sits or 
stands before him. Let us suppose that the left foot is to be adducted 
or, as the patients express it, twisted. The surgeon places the foot be- 
tween his knees ; his left hand encircles the heel, the fingers grasping 
the projecting os calcis and tendo Achillis ; the base of the palm lies 
against the medio-tarsal joint on the inner aspect of the foot ; the right 
hand grasps the outer side of the forefoot and toes ; then, by steady 
pressure of the thigh muscles, the forefoot is forced downward and in- 
ward (adducted and supinated) (Fig. 338) over the fulcrum formed by 
the projecting palm, which lies upon the left knee, the fingers holding 
the heel steadily in place. This inward twisting is at first resisted by 
a mixed voluntary and involuntary muscular spasm, which gradually 
gives way under steady pressure. When the limit of adduction has 
been reached, the foot is firmly held until all pain has subsided ; then 
the patient is instructed to attempt voluntary movements while the 
foot is guided by the hands ; in other words, the patient attempts to ad- 
duct the foot while the surgeon supplies the power, which in all cases 
of this type has been completely lost. This passive manipulation to 
the extreme limit of normal adduction, plantar and dorsal flexion, is 
continued from day to day until there is no longer a sensation of pain 
or tension; for as long as there is the slightest spasm or painful re- 
striction, so long is the voluntary motion limited, cure delayed, and 
relapse of deformity probable. During active treatment the patient, 
by the use of massage, active and passive motion, is constantly working 
to one end, namely, to regain the lost power of voluntary adduction. 

The time necessary to rest the feet, to overcome the local irritation 
and muscular spasm, to regain, in part at least, the range of passive 
motion, and to place the patient in the same position, as regards a cure, 
as that of the milder type of deformity, is from three to six weeks. 
Usually the patients are told that a month will be necessary, and that 
at the end of that time they may return to work, free from pain and 
from the danger of relapse, and that the feet will constantly grow 
stronger, under the work which was before too great for their strength. 
The time necessary to reeducate the adductor muscles in their proper 
function depends, in great degree, upon the intelligence and persistence 
of the patient. Although in after-treatment massage and special exer- 



THE RIGID WEAK FOOT. 531 

cises are of benefit, the essentials are very simple ; they are an effective 
brace, a proper shoe, and the passive manipulation that has been de- 
scribed, until its object has been attained, and the proper walk, the 
best and easiest of exercises. Finally, one must force into the patient's 
understanding the method of protecting the weak foot by the alterna- 
tion of strain, and by proper postures. 

Other Varieties of Rigid Weak Foot. — The foot, which is 
fixed in the abducted position without depression of the longitudinal 
arch, is simply one variety of the rigid weak foot, which should be treated 
in the same manner. It may be stated also, that a very large propor- 
tion of the so-called chronic sprains of the ankle are of this type, and 
that the disability will yield very readily to treatment, conducted for 
the purpose of restoring impaired function, in the manner that has 
been indicated. 

There are other cases, in which the deformity of flat foot is compli- 
cated by rheumatoid arthritis or chronic rheumatism, of which the 
evidence is seen in various joints but in which the pain and discomfort 
seem to be concentrated, in the feet, which are absolutely stiff and de- 
formed. In such cases one can hardly expect a complete cure ; but 
although the function of leverage may not be regained, still one may 
hope, by overcoming the deformity, to hold the weight of the body 
in its proper relation to the foot, so that the pain of a progressive dis- 
location may not be added to the pain of disease. In a number of 
instances forcible correction has been employed by the writer in cases 
of this type, and in all, the improvement in the general condition, 
consequently in the resistance to the disease, after the relief of the local 
pain and discomfort, has been very great. 

Between the two classes of cases, the mild and the severe, one finds 
every grade of deformity. All cases in which there is marked muscular 
spasm, local tenderness and swelling, require temporary rest ; in many 
instances, simply rest from functional use combined with massage ; in 
others, rest in a plaster bandage in the adducted position. In the 
milder and ordinary class of cases, the use of a brace and shoe will 
alone relieve spasm and pain, and the range of motion can usually be 
regained by manipulation, passive motion, and by the proper use of 
the foot. 

Occasionally, even in childhood, one may encounter marked limita- 
tion of normal motion, particularly in dorsal flexion, not due to pain and 
muscular spasm but to actual shortening of the muscle. This may be 
the accommodative shortening that is characteristic of long-standing de- 
formity ; in other instances it would appear to be the result of a slight 
and unnoticed neuritis or anterior poliomyelitis, which has resulted in 
muscular inequality. If the contraction does not yield readily to 
manipulation or to mechanical stretching, forcible correction and if 
necessary, tenotomy should be employed in the manner already de- 
scribed ; for whatever may be the theory of its causation, it is again 
emphasized that obstruction to motion in any direction must be over- 
come before a complete cure is possible. 



532 DISABILITIES AND DEFORMITIES OF THE FOOT. 

Adjuncts in Treatment. — It must be apparent, that in many in- 
stances, the cure of the weak foot is out of the question, either because 
of the want of energy or opportunity on the part of the patient, or 
because of the local or general conditions, types familiar in out-patient 
practice. 

The Thomas Treatment. — In such cases, raising and strengthening 
the inner side of the shoe by the wedge-shaped leather sole, as used by 
Thomas, splints the painful foot and aids in relieving the strain. 

Plaster Strapping. — If the symptoms are more acute, the adhesive 
plaster strapping, as advocated by Cottrell and Gibney for the treat- 
ment of sprains, is often of service, although it is applied in a different 
manner, and with a somewhat different object in view. One end of a 
strip of adhesive plaster, about fifteen inches long and three inches 
wide, is applied to the outer side of the ankle just below the external 
malleolus ; the foot is then adducted as far as possible, and the band 
is drawn tightly beneath the sole and up the inner side of the arch and 
leg, and is stayed in this position by one or two plaster strips about 
the calf. Narrow plaster straps are then applied about the arch and 
ankle, in the figure-of-eight manner, and a bandage is applied. The 
object of the dressing is to aid in holding the foot in the proper posi- 
tion, by the support and suggestiveness of the plaster, and to provide 
the firm compression about the arch that is always agreeable to the 
sufferer from weak foot. This treatment, combined with the built-up 
shoe, is often very effective in overcoming the acute and disabling 
symptoms of the weak and injured foot, which are, as has been stated, 
often the result of extra strain or injury, in other words a sprain of a 
weak foot. Consequently when these symptoms are relieved, the pa- 
tient, who has become habituated to the weakness and deformity, con- 
siders himself cured. 

Operative Treatment. — The various cutting operations for the relief 
of flat foot do not call for extended comment. The typical operation, 
the removal of a wedge from the astragalo-scaphoid region, aims at re- 
moval of deformity simply; functional cure is made impossible by the 
destruction of the medio-tarsal joint. It would hardly seem possible 
that adhesion between the astragalus and scaphoid bones could, for any 
length of time, withhold a recurrence of deformity of the nature and 
origin of flat foot, and in all cases that the writer has examined, in 
which this operation had been performed, there was still local tenderness 
and muscular spasm and even relapse of the deformity. 

The operation of advancement of the posterior extremity of the os 
calcis, as proposed by Gleich, in order that it may be placed in relation 
to the leg somewhat like that of a Pirogoff amputation, offers little 
hope of ultimate cure, because the disability is not due to primary de- 
pression of the arch, therefore it cannot be cured by exaggerating its 
depth in this manner. The most innocent and rational of the operations 
for flat foot is the supra-malleolar osteotomy of Trendelenburg, in 
which the bones of the leg are divided above the ankle, and the 
distal extremity turned inward, with the aim of directing the weight 



THE RIGID WEAK FOOT. 533 

K 
upon the outer border of the foot. In practice, the operation is by no 
means always successful, while the bow-leg deformity that results, if 
the object is attained, is an unfortunate accompaniment of the treat- 
ment. It may be mentioned in this connection that fracture at the 
ankle joint, followed by faulty union in a position of valgus, is a form 
of traumatic flat foot that may be cured by this operation. In operative 
treatment, the element of rest, necessary for weeks or months, must be 
taken into consideration, as explaining in part, the immediate favorable 
effect of whatever procedure is adopted. An investigation of final re- 
sults will prove, I believe, as might be predicted from the nature of 
the deformity and the complex structure of the foot, that there is no 
short and easy method by which a cure may be attained. 

In conclusion, the following points are again emphasized : Flat foot 
in its surgical sense, is a compound deformity, in which the abnormal 
relation between the foot and the leg, causing the improper distribution 
of the weight and strain, and disuse of normal function, is of vastly 
greater importance than the depression of the arch, which has given 
the name to the disability. 

The weak and deformed foot can be cured, but only by the applica- 
tion of the simple principles that any mechanic would apply to a dis- 
abled machine whose structure and use were known to him ; in other 
words, there can be no permanent cure of weakness and deformity un- 
less normal function is regained, or effective treatment unless it has 
this end in view. 

The term weak foot has this advantage over others that imply de- 
formity, in that it may include the earliest indications of disability. Once 
weakness is recognized, its causes may be analyzed and appreciated at 
their proper value. Flat foot is a particularly objectionable and mis- 
leading term, and it should be discarded, or at least used only to de- 
scribe those cases to which it can properly be applied. 



CHAPTER XXI. 

DISABILITIES AND DEFORMITIES OF THE 
FOOT.— Continued. 

The Hollow or Contracted Foot. 

Synonyms. — Non-deforming Club Foot, Talipes Arcuatus, Talipes 
Plantaris, Talipes Cavus. 

The depth of the arch and the corresponding area of the bearing sur- 
face of the sole of the foot vary greatly in different individuals, and, 
although marked differences in appearance and function are possible 
within a normal range, yet, as a rule, the low arch is characterized 
by a certain relaxation and weakness of structure, while the exag- 
gerated arch implies a corresponding contraction and loss of normal 
elasticity. 

The hollow or contracted foot may be divided into two classes ; the 
simple and the compound. In the first class, the simple exaggeration 
of the arch (talipes arcuatus) is the only change from the normal 
condition. In the second, the high arch is combined with a certain 
limitation of the range of dorsal flexion at the ankle joint (talipes 
plantaris — Fisher). 

Etiology. — The simple hollow foot may be an inherited peculiarity. 
The depth of the arch may be exaggerated by the habitual use of high 
heels (postural equinus), or by excessive use of the calf muscle, as by 
professional dancers. 

The compound variety, in which the hollow foot is combined with 
slight equinus, may be inherited also ; but in most instances, its origin 
may be traced to a mild and transient form of anterior poliomyelitis 
or neuritis in early childhood. This causes temporary weakness of 
the anterior group of muscles of the leg, and thus a slight toe drop, 
followed by secondary contraction of the tissues of the sole and of the 
muscles of the calf. In the history of many of these patients it will 
be found that after recovery from scarlatina or other contagious or 
infectious disease, the child seemed weak or awkward. These symp- 
toms became less marked or practically disappeared ; yet a trace re- 
mained, although not of sufficient importance to call for treatment, 
until adolescence or adult life, when the greater strain and weight put 
upon the feet brought to light the latent disability. The affection may 
undoubtedly develop in later years as the result of neuritis, or of gout 
or rheumatism. It may be caused by a sprain or fracture of the 
ankle, and it may be a result of habitual posture to compensate for a 
leg shortened by injury or disease. 



SYMPTOMS. 



535 



The exaggerated arch which is a part of a more important deformity, 
as of equino-varus or calcaneus, or that which is simply a part of the 
general deformity caused by diseases of the nervous apparatus, does 
not belong to the class of disability under consideration. 

Symptoms. — The simple hollow foot often exists without symptoms, 
in fact it is often considered as a particularly well formed foot rather 
than a deformity. The usual complaint in these cases is that one is 
unable to buy comfortable shoes because the ordinary shoe does not 
support the arch, or because the upper leather exerts uncomfortable 
pressure on the dorsum of the foot. The convexity of the dorsum of 
course corresponds to the depth of the arch, and in many instances, the 

Fig. 369. 




The contracted foot of slight degree. 



cuneiform bones project sharply beneath the skin, and painful pressure 
points or even inflamed bursse in this locality may cause discomfort. 

In the well-marked cases in which the weight is borne entirely on 
the heel and the front of the foot, calluses and corns often form at the 
center of the heel and beneath the heads of the metatarsal bones. The 
patient may complain of neuralgic pain about the great toe, the meta- 
tarsal arch, or in the sole of the foot. The gait is often ungraceful, as 
the patient walks heavily upon the heels with feet turned outward. In 
such cases " the ankles may be weak and turn easily.'' In the more 
advanced cases of this type, the foot may assume the position of valgus 
when weight is borne, so that the more noticeable symptoms are those 



536 



DISABILITIES AND DEFORMITIES OF THE FOOT 



of the weak foot or so-called flat foot, even though the depth of the arch 
is exaggerated. 

Contracted foot, of the more severe grade, is almost always accom- 
panied by a certain limitation of dorsal flexion ; and as the shortening 
of the plantar fascia is often more marked at its inner border, a slight 
inversion of the forefoot or varus may be present also. 

When the exaggerated arch is combined with limitation of dorsal 
flexion the deformity becomes compound. This limitation may be very 
slight, or it may be well marked ; and a slight degree of permanent 

equinus even, may be present, 
Fig. 370. but so slight that it does not, as 

a rule, attract attention. 

This type of the contracted 
foot was first clearly described 
by Shaffer in 1885, under the 
title of " non-deforming club 
foot " l and later by Fisher, of 
London, as " talipes plantaris." 
The symptoms are similar to 
those of the simple hollow foot, 
but they are almost always more 
marked. The gait is awkward 
and jarring, the feet being turned 
outward to an exaggerated de- 
gree ; the patient is easily fa- 
tigued, and often complains of 
the weakness about the ankle and 
inner side of the arch, character- 
istic of the weak foot, and of 
sensations of tire and strain in 
the calf of the leg. The discom- 
fort from corns, the pain referred to the metatarsal region, the great 
toe, and to the sole of the foot have been described already. 

On examination the exaggeration of the arch is evident ; and an im- 
print of the sole shows that the weight is borne entirely on the heel, 
and on the heads of the metatarsal bones which may be very promi- 
nent beneath the thickened skin, as if the subcutaneous pad of fat had 
been absorbed. The anterior metatarsal arch is often obliterated, and 
the toes are usually habitually dorsi-flexed at the first phalanges, the 
permanent flexion and thus pressure against the leather of the shoe 
being shown by a row of corns upon their dorsal surface. (Fig. 370.) 
The contracted plantar fascia may be demonstrated by forcible dorsal 
flexion of the foot, when the tense bands, in many instances very sen- 
sitive to pressure, may be felt beneath the skin. 

On testing the motion of the foot, the limitation of dorsal flexion, 
both of the voluntary and the passive range, will be evident. In 
voluntary flexion, the toes are drawn up and the tendons are plainly 
*K Y. Med. Kec, May 23, 1885. 




Contracted foot, marked. 



OPERATIVE TREATMENT. 537 

seen on the dorsum, showing the effort made by the accessory muscles 
to overcome the abnormal resistance. 

The limitations of dorsal flexion may be demonstrated in the manner 
suggested by Shaffer, by asking the patient to flex the feet, while stand- 
ing erect with the back to the wall, when in spite of the effort made, 
" the feet remain glued to the floor." 

Treatment. — In the ordinary form of contracted foot, as has been 
stated, the disability is much more marked than the deformity ; and 
the disability is due to secondary changes in the structure of the foot, 
by which its elasticity is impaired. If this contraction is removed 
permanent relief will follow. If the simple hollow foot (cavus), or the 
compound type (plantaris), were discovered in early childhood, massage 
and methodical stretching would, in all probability, be sufficient to re- 
lieve the contraction ; but as a rule no symptoms are noticed until later 
life. Even then, especially in the simple form, they are often slight and 
may be relieved by a shoe with a broad heel and a high (Spanish) 
arch or by a foot plate that equalizes the pressure on the sole. 

In the more advanced cases of the milder type, methodical mechan- 
ical stretching of the parts by means of the Shaffer l " traction shoe " 
may elongate the tissues sufficiently to relieve the symptoms ; but in 
the more resistant cases division of the contracted parts and forcible 
correction of deformity is indicated. 

Operative Treatment. — The patient having been anaesthetized, a teno- 
tomy knife is introduced beneath the skin to the inner side of the central 
band of fascia. This is divided by a sawing motion, and if on forced 
dorsal flexion other tense bands appear they are divided also. Forcible 
massage, with the aim of making the foot flexible and reducing the 
depth of the arch, is then employed. If sufficient force cannot be em- 
ployed by the hands, the Thomas wrench may be used as in the treat- 
ment of club foot ; the object being to elongate the foot, to remove the 
contraction and thus by increasing the area of bearing surface to relieve 
the painful pressure on the heads of the metatarsal bones. If the con- 
traction of the tendo Achillis can not be overcome by forcible manipu- 
lation it may be divided. The foot, held in an attitude of dorsal flexion, 
is then fixed in a well-fitting plaster bandage, a thin board, shaped to 
the foot, having been incorporated in the bandage, in order that firm 
and even pressure may be exerted upon the sole. As soon as possible, 
often on the following day, the patient is encouraged to walk about, in 
order that the pressure of the body-weight may be utilized to flatten 
the foot still more, while its tissues are in a yielding condition. 

The bandage may be worn for six weeks, or if the tendo Achillis has 
been divided until its repair is complete. A well-fitting shoe should 
be worn, and methodical massage, and stretching of the tissues should 
be continued as long as the tendency to deformity remains. By this 
treatment the symptoms may be relieved and in many instances, a re- 
turn to the normal shape and function can be assured. 

•X. Y. Med. Jour., March 5, 1887. 



538 DISABILITIES AND DEFORMITIES OF THE FOOT. 

Weakness of the Anterior Metatarsal Arch. 

Anterior Metatarsalgia and Morton's Neuralgia. — A peculiar spas- 
modic pain about the fourth toe was described by Morton of Phila- 
delphia long before its predisposing and exciting causes were under- 
stood. For this reason a description of the symptoms may with 
advantage precede a consideration of the weakness of which they are 
usually the result. 

Typical cases of Morton's l painful affection of the foot are charac- 
terized by a sudden cramp-like pain in the region of the fourth meta- 
tarso-phalangeal articulation. 

The pain may begin as a burning sensation beneath the toe, as a sud- 
den cramp or as a peculiar feeling of discomfort about the articulation 
that increases in severity until it becomes almost unbearable. At first 
the pain is confined to the neighborhood of the affected joint, but unless 
it is relieved, it radiates to the extremity of the toe to the dorsum of the 
foot or up the leg. In many instances the onset of the pain is preceded 
by the sensation of something moving or slipping in the foot ; in some 
cases the pain may be induced by sudden movements, missteps or long 
standing, and in practically all the cases the pain is felt only when the 
shoes are worn. The frequency of the recurrent cramp varies ; in 
some cases it is felt only at infrequent intervals ; in others it practically 
disables the patient. When the cramp habit has been acquired, very 
slight causes may induce the pain, for example, a thin-soled shoe, a hot 
pavement, " the sticking of the sock to the foot " and the like, but, 
as has been stated, except in the very advanced and chronic cases, the 
pain is never felt except when the shoe is worn. 

To relieve the pain, the patient removes the shoe, rubs and com- 
presses the front of the foot, flexes and extends the toes and the like. 
After the cramp is relieved, a sensation of soreness remains, and occa- 
sionally slight swelling may appear, but in most instances there are no 
external signs, although the affected articulation is usually sensitive to 
deep pressure at all times. 

The more distinctive term anterior metatarsalgia, a term suggested 
by Poulosson of Lyons in 1889, may be employed to include Morton's 
neuralgia, and similar symptoms of pain and discomfort about the 
anterior metatarsal arch. For in many instances, the cramp-like pain 
is referred to other points, for example, to several adjoining joints, or 
the discomfort caused apparently by direct pressure on the bones of 
the weakened arch may be more troublesome than the irregular attacks 
of neuralgic pain. 

Etiology and Pathology. — In seventy-eight cases of anterior meta- 
tarsalgia in which the location of the pain was noted, it was referred 
to the fourth metatarso-phalangeal articulation in sixty ; to the third 
and fourth articulation in six ; to the second, third and fourth in six, 
and in but six, was the fourth articulation free from pain. The pain is 
most often unilateral, or if the second foot is affected, it is usually after 
a considerable interval. 

1 T. G. Morton, Am. Jour. Med. Sci., Aug., 1876. 



THE ANTERIOR METATARSAL ARCH. 539 

The affection is more common in females than in males. Of eighty- 
four cases, sixty-four were in women and twenty were in men. 

Anterior metatarsalgia is not an affection of early life, the average 
age in the reported cases being more than thirty years. It is rela- 
tively more frequent in private than in hospital practice, and not in- 
frequently the patients are of a distinctly nervous type. The affection 
is usually extremely chronic. Occasionally the symptoms may cease 
spontaneously, and in such instances a particular pattern of shoe usually 
receives the credit of the cure. 

Morton considered the affection to be a painful affection of the 
plantar nerves due to compression or pinching by the adjoining fourth 
and fifth metatarso-phalangeal articulations. This compression was 
explained by the anatomical construction of the foot, i. e., the mobility 
of the fifth metatarsal bone which allowed it to roll above and under 
the fourth, its relative shortness which allowed the head and base of 
the adjoining phalanx to be brought against the adjoining head and 
neck of the fourth bone, and finally, by the peculiar distribution of the 
external plantar nerve between these bones that made it or its fibers 
more liable to injury. This natural mobility and thus the predisposi- 
tion to compression might be exaggerated by a sprain, or possibly by rup- 
ture of the transverse metatarsal ligament, or the pain might be induced 
by wearing tight shoes, but in many instances, no cause could be as- 
signed. On this theory, Morton advocated excision of the head of the 
fourth metatarsal bone to remove the point of counter-pressure. This 
operation has been performed many times, but practically no patho- 
logical changes in the resected bone or in the surrounding parts have 
ever been discovered. 

In more recent years the true significance of Morton's neuralgia and 
of similar pains in the front of the foot, has been made more clear by 
the study of the relation of weakness of the anterior transverse meta- 
tarsal arch to the symptoms. Attention was first called to this point 
by Poulosson of Lyons, and again by Houghton, Woodruff and others, 
and in a much more thorough and convincing manner by Goldthwait l 
of Boston, in 1894. 

The Anterior Metatarsal Arch. — If one examines a normal foot, one 
notices that the two middle metatarsal bones, the second and third, 
are slightly longer and on a higher plane than their fellows. On the 
sole of the foot the arch is shown by the depression immediately to the 
outer side of the muscular projection of the great toe joint. When 
weight is borne, all the metatarsal bones are on the same plane and the 
arch is obliterated, but when the weight is removed, the arch reforms 
with a certain natural resiliency. In walking and standing, the weight 
is balanced on the head of the third metatarsal bone as is shown by a 
thickening of the skin beneath its head, but the strain on the metatar- 
sal arch is relieved somewhat by the balancing action of the muscles 
about the first and fifth metatarsal bones, the inner and outer supports 
of the arch, and by the active assistance of the toes themselves. When 
Boston Med. and Surg. Jour., Vol. 131, p. 233. 



540 DISABILITIES AND DEFORMITIES OF THE FOOT 

the arch is weak or broken down, this natural resiliency is lost, and, 
in some instances, the center of the forefoot is not only depressed but 
it is fixed in this abDormal attitude. 

In the ordinary type of depressed anterior arch, the deformity may 
be shown by an imprint of the foot, in which the flabby tissues of the 
depressed arch encroach upon the clear space representing the longi- 
tudinal arch, and obliterate what Goldthwait calls the reentering angle 
to the outer side of the great toe joint, which in the normal foot indi- 
cates the highest point of the metatarsal arch. In many instances 
however, the imprint of the foot subject to Morton's neuralgia may be, 
to all intents, normal and on the other hand depression of the meta- 
tarsal arch, one of the very common results of improper shoes, may be 
present, yet unaccompanied by pain or discomfort. 

Depression of the anterior arch, the result of the loss of the activity 
of the accessory supports of the arch, predisposes to pain because of 




Position of the fingers corresponding to dorsi-flexion of the toes, an attitude in which lateral 

pressure causes pain. 

abnormal pressure upon the persistently depressed articulations from 
beneath, and it predisposes to pain, as the writer has endeavored 1 to 
explain, because the metatarsophalangeal joints of the arch, which is 
habitually depressed, cannot escape direct lateral compression, if it is 
exerted by the shoe or otherwise. 

This point may be illustrated in the hand. When lateral pressure 
is applied, the hand is folded together and the anterior metacarpal arch 
is increased in depth, but if the fingers be dorsi-flexed so that it 
is fixed in a depressed position, then lateral compression causes great 
pain at all the articulations (Fig. 371) ; or if one finger is dorsi-flexed and 
the corresponding metacarpal bone is thus forced below the level of its 
fellows, lateral compression causes pain at the compressed joint. Or 
if the matacarpal bone of the little finger is made to override the 

1 N. Y. Med. Kec, August 6, 1898. 



ETIOLOGY AND PATHOLOGY. 541 

fourth, lateral pressure causes paiu usually of a more acute character 
than at the other joints, because the opportunity for direct pressure is 
more favorable. 1 Finally if firm pressure is made upon one or the other 
side of the head of the depressed metacarpal bone of the dorsi-flexed 
finger in the palm of the hand, a point of sensitiveness, representing 
apparently the digital nerve, can be made out. The same experiments 
may be tried upon the foot Avith the same results, and it would seem 
to make clear the mechanism of the pain of Morton's neuralgia, and 
the allied forms of discomfort at the front of the foot. 

Anterior metatarsalgia is in most instances the result of weakness 
or depression of the anterior metatarsal arch as a whole or in part, and 
the quality of the pain corresponds fairly to the form of weakness or 
deformity. If, for example, the entire arch is rigidly depressed, as in 
certain rheumatic affections, the discomfort is likely to be caused, in 
great degree, by the direct pressure of the sensitive depressed meta- 
tarsophalangeal joints on the sole of the shoe, or if lateral pressure is 
exerted as well, the more acute discomfort or pain may be referred to 
the metatarsal arch in general. If the metatarsal arch is weakened, 
depressed and broadened but not rigid, the discomfort is often referred, 
as in the preceding instance, to the center of the arch, and this dis- 
comfort is increased, in some instances, by a painful callus representing 
abnormal pressure at this point. If one of the metatarsal bones falls 
below its fellows, the lateral pressure of a narrow shoe may cause neu- 
ralgic pain at this joint, but in many instances, in which the anterior 
arch is depressed the patient makes but little complaint of pain. In 
certain instances, more particularly those of Morton's typical neuralgia, 
the foot may appear to all intents normal ; in such cases it may be in- 
ferred that the sharp and characteristic pain is caused by pressure ap- 
plied to the over-riding fifth metatarsal bone, just as similar pain is felt 
if the hand is suddenly compressed while the fifth metacarpal bone is 
in a similar position. This theory is the more probable when one con- 
siders the symptoms ; for example, the sensation of something slipping 
or moving, the necessity for the removal of the shoe to flex and extend 
the toes and to compress the foot, apparently with the instinctive aim 
of replacing a depressed arch, or a misplaced bone in the arch. It 
would also explain how the shoe may be the most direct of the exciting 
causes of the deformity, in that it compresses the forefoot, and throws 
more weight upon it by elevating the heel. If the arch is depressed 
or becomes depressed, or if a bone in the arch over-rides another, this 
compression causes the symptoms. 

The Influence of the Shoe in Causing Disability and Pain. — In the 
etiology of pain and discomfort about the anterior arch, one must 
recognize the shoe, not only as the direct cause of the pain, but also 
as the most important of the predisposing causes of weakness of the 
anterior arch, of which the pain is a symptom, since it compresses the 
toes, lifts them off the ground by its " rocker sole," and thus, by pre- 
venting their normal function, throws additional strain and pressure 
1 This anatomical peculiarity is well known to school boys. 



542 DISABILITIES AND DEFORMITIES OF THE FOOT 

upon the arch. In fact in a very large proportion of feet that are 
supposed to be normal in appearance and functional ability, the toes 
are habitually dorsi-flexed in a claw-like attitude, that shows entire 
disuse of their function both as a support and in progression. Women 
wear shoes with narrower soles and higher heels than men, and this 
seems the most reasonable explanation of the fact that they are more 
subject to the affection. 

The shoe also predisposes to habitual elevation of the fifth meta- 
tarsal bone, because this bone almost invariably overhangs the narrow 
sole, so that the fourth metatarsal bone becomes the outer support of 
the arch, and is almost always found to be on a lower level than the 
adjoining bones ; a fact which, together with the natural mobility that 
may have become increased by injury or otherwise, may account for the 
location of the pain at this point in the majority of cases. Although 
in certain instances a neuritis may follow direct injury, yet this assump- 
tion is not at all necessary to explain the symptoms. Nor is it likely 
that the peculiar distribution of the nerves at this point has any direct 
influence on the pain, for the nerve supply of all the joints and all the 
toes is practically identical. 

Other Factors in the Etiology. — Besides the general effect of the shoe, 
and the possible influence of inherited predisposition to the affection, 
which seems evident in certain cases, or of weakness or direct injury of 
the anterior arch, one recognizes among the causes or complications of 
anterior metatarsalgia, weakness of the longitudinal arch or flat foot, 
which may be combined with a depression of the anterior arch. Less 
often the longitudinal arch may be exaggerated in depth and the dorsal 
flexion of the foot may be limited by a shortened tendo Achillis, thus 
more pressure is brought upon the front of the foot. In these cases, 
the pain may be increased by corns or calloused skin beneath the de- 
pressed bones and in many instances the discomfort of the depressed 
arch of the ordinary type is, in great part, caused by a sensitive corn or 
fibroma at the point of greatest depression, and the patient may be 
entirely relieved by its removal. (See contracted foot.) 

Although the symptoms of anterior metatarsalgia may be explained 
in most instances by the primary effect of improper shoes, by weak- 
ness and abnormality of the foot itself, and by the local sensitiveness 
of the parts that are continually subjected to strain pressure and injury, 
yet in some instances the symptoms can be explained only by local 
neuritis ; in others, they are aggravated by gout or rheumatism or 
general debility, and as has been stated in a large proportion of the 
cases the patients are of a distinctly nervous type. 

Treatment. — The most important local treatment is to provide the 
patient with a proper shoe. This shoe must be of proper shape with 
a thick sole, so broad that no lateral compression of the toes is possi- 
ble, with a high arch, as suggested by Gibney, in order to remove a part 
of the pressure from the heads of the metatarsal bones, and a low heel. 

As an immediate treatment, a firm bandage about the metatarsal re- 
gion, as suggested by Morton, may aid in supporting the metatarsal 



TREATMENT. 



543 



arch, or better, adhesive plaster strapping may be applied about the 
metatarsus. Beneath or slightly behind the affected joint or the de- 
pressed arch, a pad, preferably an oval piece of sole leather, 
about one inch by three-quarters of an inch in size and one-quar- 
ter in thickness with bevelled edges, may be fixed to the sole of 
the foot with adhesive plaster, so that depression of the arch or over- 
riding of the adjoining bones may be prevented. This pad, suggested 
by Poulosson and Goldthwait, almost always relieves the pain, and 
w T hen the exact place has been ascertained, it may be fixed to the sole 
of the shoe. 

As a rule, however, a metal support will be found to be more com- 
fortable and more efficient. This may be constructed of light steel (19 
gauge) upon a plaster cast of the sole of the foot, 
of which the natural depressions, indicating the Fig. 372. 

anterior and the longitudinal arches, have been 
somewhat exaggerated. The anterior extremity 
of the brace is made as wide as the foot, and ex- 
tends forward slightly beyond the metatarso- 
phalangeal articulations. The brace serves to 
support the anterior as well as the longitudinal 
arch. If there is slight depression of the longi- 
tudinal arch it may be further corrected by rais- 
ing the inner border of the heel and sole of the 
shoe, but if it is more pronounced a flat foot 
brace (Fig. 365) may be employed, whose an- 
terior extremity is modified to support the met- 
atarsal arch, as is shown in Fig. 372. If, on 
the other hand, the arch is exaggerated and if 
dorsal flexion is limited, treatment with the aim 
of relieving this deformity will be necessary, as 
described under "contracted foot." When the 
immediate symptoms of pain and local discomfort 
have been relieved, the patient must endeavor to 
strengthen the natural supports of the arch by 
proper functional use of the foot, and by regular 
exercise of the muscles, more especially by metho- 
dical forced flexion of the toes, as this motion elevates the anterior 
metatarsal arch. (Fig. 373.) 

If the anterior arch is rigidly depressed as in some instances, its 
flexibility must be restored by manipulation or by forcible correction 
under anaesthesia before a brace can be applied. If the symptoms are 
very acute, and particularly if they have followed direct injury, the 
parts should be placed at rest and the anterior arch should be elevated 
and supported by a properly applied plaster bandage. 

In chronic and resistant cases, or when conservative treatment cannot 
be applied, resection of the neck and head of the metatarsal bone at 
the seat of pain may be performed as advocated by Morton. The op- 
eration is very simple. An incision is made over the dorsal surface of 




A brace for anterior 
metatarsalgia. A indicates 
a point beneath the fourth 
metatarso-phalangeal artic- 
ulation which is elevated in 
order to support the de- 
pressed articulation. 



544 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



the joint, and the bone is separated by bone forceps. The toe is not, 
as a rule, removed, but after the operation it slowly recedes between 
the adjoining metatarso-phalangeal joints, causing a rather noticeable 
deformity. The operation is, as a rule, successful, but in the majority 
of cases it is unnecessary. 

The general condition of the patient should of course receive atten- 
tion, and local applications, electricity and the like, may be of benefit 
in special cases. 

A sensitive callus beneath the arch may require removal, and in 
certain cases its removal may be the only treatment required other 
than an improved shoe. But as a rule, the cause of the callus is habitual 
depression of one or more of the metatarso-phalangeal articulations, so 



Fig. 373. 




Exercise for the weakened metatarsal arch. 

that cure can only be assured by supporting the arch and by strength- 
ening its natural supports in the manner already described. 

Woodruff ! described a case of what he called " incomplete luxation 
of the metatarso-phalangeal articulation" in which the symptoms, 
practically identical with those of Mortion's neuralgia, are ascribed to 
an upward displacement of the proximal phalanx of the fourth meta- 
tarsal bone. 

Another writer, Guthrie, 2 described a case in which intense pain 
followed over-extension of the third phalanx upon the second. Such 
cases are extremely uncommon and need only be mentioned. 

Achillo -Bursitis. 

— Synonyms. — Achillodynia, Achillo-bursitis Anterior, Eetro-calca- 
neo Bursitis. 

Under the title of achillodynia, Albert, 3 of Vienna, in 1893 called 
particular attention to an affection characterized by pain and tender- 
ness about the insertion of the tendo Achillis, symptoms usually 

J N. Y. Med. Eecord, Jan. 18, 1887. 
2 Lancet, March 19, 1892. 
3 Wien Med. Presse, Jan. 8, 1893. 



ACHILL0-BURS1TIS. 545 

caused by irritation or inflammation of the small bursa lying between 
the insertion of the tendon and the bone. (Fig. 374.) 

Etiology. — In the acute cases, the cause of the bursitis often appears 
to be a strain of the tendon or direct injury, as the symptoms appear 
immediately after running or jumping or after a fall, sometimes after 
a long walk or bicycle ride. 

In the subacute cases, the symptoms may begin almost impercepti- 
bly, so that it may be impossible to assign a direct cause other than 
the pressure of the shoe, aggravated it may be, by an exostosis of the 
os calcis beneath the insertion of the tendon or by concretions within 
the bursa. In many instances. rheumatism, gout, gonorrhoea or one of 
the infectious diseases, appear to be associated, directly or indirectly, 
with the onset of the symptoms, or the bursa 
may be secondarily involved in tuberculous dis- Fig. 374. 

ease of the os calcis. 

Symptoms. — In a typical case, pain is felt in 
the back of the heel at the insertion of the 
tendon ; the pain is increased by use of the 
foot, and particularly by the attitudes in which 
the strain on the part is increased, as, for ex- 
ample, in descending stairs. There is also ten- 
derness on pressure about the back of the heel 
on either side of the insertion of the tendon. 
In most cases, a slight swelling, often more 
prominent on the inner than the outer side of 
the tendon, indicates the situation of the bursa. 

In the chronic cases, the enlargement of the 

, . ( . , , ' , . -P -i • . i Bursa between the tendo 

bursa is very noticeable, and in addition, the en- acmius and the os caicis. 
tire posterior aspect of the heel often appears to 

be thickened. This is due probably to the secondary irritation about 
the fibrous expansion of the tendon and the adjoining periosteum. In 
many cases, the symptoms are pronounced ; pain is often felt in the 
bottom of the heel or it radiates up the back of the leg. The patient, 
unable to use the power of the calf muscle, everts the foot in walking, 
thus subjecting the arch to over-strain, so that the symptoms of the 
weak foot are often added to those of the original trouble. Not in- 
frequently however the two affections may be associated from the be- 
ginning in one or the other foot. The patient complains much of 
stiffness and weakness at the ankle and sub-astragaloid joints. In the 
acute cases, or in acute exacerbations there is usually burning and 
throbbing pain characteristic of acute inflammation, but in the sub- 
acute form the pain is slight, and is troublesome only after over-exertion. 
Pathology. — The pathological changes do not differ from those 
found in and about other bursa? under similar conditions. In the 
mild cases the lining membrane is simply congested and the cavity 
contains serous fluid. In the chronic cases, the walls are much thick- 
ened, 1 the lining membrane is fringed and reduplicated ; the contents 

dossier, d. Z. f. Chir., Bd. 42, 1 and 3. 
35 




546 DISABILITIES AND DEFORMITIES OF THE FOOT. 

are semi-solid, and sometimes calcareous masses are present. Similar 
changes are found however, in the bursa? of apparently normal sub- 
jects, so that the condition of the bursa may not always correspond 
to the character of the symptoms. Suppuration of the sac occa- 
sionally occurs, and it may be the seat of tuberculous or syphili- 
tic disease. In cases of long standing, the parts adjoining the bursa, 
the expansion of the tendon and the periosteum become thickened 
so that the bone appears to be increased in breadth and may actually 
become so. 

Treatment. — When once established, the affection is usually of a 
very chronic nature, as is explained by the strain to which the sensitive 
part is subjected by the use of the foot. It is therefore important 
to apply efficient treatment at the beginning of the affection if an op- 
portunity is afforded. Efficient treatment implies absolute rest, and in 
all cases of any severity, particularly those of acute onset, a well-fitting 
plaster bandage should be applied to hold the foot slightly inverted 
and at a right angle to the leg. This should be worn until all symp- 
toms have subsided. In very mild cases, following immediately on 
a strain or over-use, simple rest with the application of heat, massage, 
and pressure, may be efficient. And in the subacute cases, the symptoms 
may be relieved by the application of a long broad band of adhesive 
plaster, from the toes over the back of the heel to the upper third of 
the calf, the foot being slightly plantar flexed. This is firmly fixed 
by narrow strips of plaster about the metatarsus, the heel and the calf. 
By this means pressure is exerted upon the bursa, and much of the 
strain is removed from the tendon. 

In persistent cases, a brace may be used with advantage, for the 
purpose of preventing strain upon the tendon. Two lateral uprights 
with a calf band and padded strap that crosses the upper third of the 
leg are attached to the shoe, provided with a stop joint at the ankle 
as used in the treatment of paralytic calcaneus to prevent dorsal flexion. 
(See talipes.) As the patient is usually sensitive to jar, the heel of 
the shoe should be replaced by one of thick rubber. In connection 
with the brace, the stimulation of the cautery and the pressure of the 
adhesive plaster strapping seem to hasten the absorption of the effu- 
sion in and about the bursa. If weakness or depression of the arch 
is present, as a result of the disability or combined with it, a foot 
plate should be applied (see page 525), and general affections, with 
which the disability is sometimes associated, should of coursej receive 
attention. 

Operative Treatment. — In chronic cases, in which the symptoms are 
not relieved by treatment, the enlarged bursa may be removed by an 
incision on one or both sides of the tendon. A plaster bandage is 
then applied and is continued until the symptoms have subsided. 
Operative treatment is of course indicated in acute suppurative in- 
flammation, in tuberculous disease, or if an exostosis beneath the bursa 
or concretions within the sac are present, as shown by the X-ray 
photograph. 



PAINFUL HEEL. 547 



Achillo-Bursitis Posterior. 



Tenderness, pain and swelling at the back of the heel may be due 
to inflammation of the small superficial bursa that lies between the 
tendon and the skin. The cause is usually injury or the pressure of 
the shoe. The symptoms resemble somewhat those of achillo-bursitis 
anterior, but the swelling is more superficial, and the pain is caused 
by direct pressure rather than by tension on the tendo Achillis. In the 
ordinary case, removal of the pressure will at once relieve the symp- 
toms, but if the discomfort is considerable, a plaster bandage may 
be worn for a week or more. 

Sensitive points at the back of the heel are usually caused by the 
pressure of the shoe ; in rare instances, prominent points, or exostoses 
of the os calcis are present, that may require special protection or re- 
moval. 

Strain of the Tendo Achillis. 

Not infrequently, and usually as the result of strain or over-use of 
the foot, patients complain of symptoms similar to those of achillo- 
bursitis, but on examination, one finds that the pain and sensitiveness 
are referred to the tendon itself. There is no swelling at its insertion, 
or pain on lateral pressure on the os calcis. The sensitive area may 
be as high up as the junction of the tendon with the muscle, and 
again, the mid-point of the tendon seems most painful. 

The cause in some cases may be a direct strain of the tendon or of 
the muscular fibers near its origin, or inflammation of its fibrous cov- 
ering due probably to the same cause. The treatment is similar to 
that of the milder type of achillo-bursitis, by the adhesive plaster 
strapping, by rest, and later, by massage. Recovery is usually rapid. 

Painful Heel — Calcaneo-Bursitis. 

Pain referred to the bottom of the heel, and sensitiveness to pres- 
sure on standing, are common symptoms of the weak or flat foot. 
Pain at this point may be one of the symptoms of achillo-bursitis also. 
In rare instances, the painful point is clearly localized and is confined 
to a small area in the neighborhood of the inner tuberosity of the os 
calcis. The cause of the symptoms, in such cases, may be an inflamed 
bursa lying between the periosteum and the fatty tissue of the heel. 
Such bursa? may contain hard substances or even a fasciculated neu- 
roma. 1 

More general pain and tenderness referred to the heel, is often 
caused by the direct pressure and bruising of the tissues by over-use 
of the feet. 

Treatment. — Treatment must be directed to the condition of which 
the pain is a symptom, and, as has been stated, it is most often one of 
the symptoms of the weak or broken-down arch. If the tender point is 
^rousses & Berthier, Kevue de Chir., Aug., 1895. 






548 DISABILITIES AND DEFORMITIES OF THE FOOT. 

localized, and if the pain is increased by jars, a thick rubber heel com- 
bined with an inner sole, so cut out as to remove the direct pressure 
on the sensitive point, will often relieve the symptoms. In persistent 
cases, in which the sensitive point is distinctly localized, operative in- 
tervention for the removal of the bursa is indicated. The tissues of 
the heel may be turned back in a horseshoe-shaped flap which will 
allow a thorough examination of the affected parts. 1 

Sensitiveness due to direct contusion, or bruising of the tissue caused 
by over-use, must be treated by rest and by change of occupation, un- 
less a reduction of the body- weight or improvement in attitudes re- 
lieve the symptoms. 

Plantar Neuralgia. 

Synonym . — Plan talgia . 

Pain referred to the sole of the foot, and sensitiveness to pressure 
on the plantar fascia, are usually symptomatic of the contracted foot 
(cavus) ; less often such symptoms accompany the weak or broken- 
down arch. 

Pain, tenderness and thickening of the fascia sometimes follow in- 
jury (rupture of the fascia), 2 and a similar condition has been de- 
scribed by Franke as one of the sequelae of influenza. 3 

Treatment. — Pain in the sole of the foot, symptomatic of the con- 
tracted or of the weak foot, may be relieved by the treatment of the 
conditions of which it is a symptom. In the rare instances in which 
the fascia is itself injured or diseased, local rest, as afforded by the 
plaster bandage, is indicated until the acute symptoms have subsided. 

Erythromelalgia. 

Wier Mitchell 4 has described a series of cases characterized by attacks 
of heat, redness, pain and often swelling of the soles of the feet. Of 27 
cases all but two were in women, many of whom were of a nervous or 
neurasthenic type. The affection appears to be a form of vaso-motor 
disturbance. Disturbances of the circulation and burning pain in the 
soles of the feet are common symptoms of the weak foot and of allied 
affections, but simple erythromelalgia unaccompanied by disability of 
this character is uncommon. It deserves mention however as a pos- 
sible explanation of symptoms in obscure cases. 5 

Hallux Rigidus. 

Synonyms. — Hallux Flexus, Painful Great Toe. 
Hallux rigidus is a painful affection of the great toe joint, character- 
ized by restriction of motion, particularly of the range of dorsal flexion. 

iDuplay, Clin. Chir. del' Hotel Dieu. Serie, 1897. 

2 Lederhose, Verhand. der Deut. G. fur Chir., XXIII. , Kong, 1894. 

3 Archiv f. Klin. Chir., Bd. 49, 1895. 

4 Am. Jour. Med. Sci., Vol. 76, 1878. 

5 Prentiss, Trans. Am. Ass'n Physicians, Vol. XII., 1897, p. 303. 



HALLUX BIGIDUS. 



54:9 



Fig. 375. 



In advanced cases, the first phalanx may be slightly plantar flexed 
together with its metatarsal bone, hence the name hallux flexus, ap- 
plied by Davies-Colley, who first described the affection. 

The restriction of motion may be complete, as implied by the term 
rigidus ; the joint appears unduly prominent or enlarged, usually 
slightly congested, and pressure or forced movement causes pain. j 

The symptoms of which the patient complains are a burning~or 
throbbing pain in the joint, increased by standing and particularly by 
walking, because of the enforced movement of the stiff and painful 
articulation. In many cases there is no actual deformity of the joint 
or other change ; the restriction of motion is much less, and the symp- 
toms are correspondingly slight. 

Etiology. — Typical hallux rigidus is most common in adolescence, 
and it is very often associated with the weak or broken-down foot. 
In such cases, the toe is crowded into the narrow part of the shoe, and 
is thus subjected to lateral and to longitudinal pressure as well as to 
the additional strain, that the attitude, characteristic of the weak foot, 
throws upon it. In some cases the habitual plantar flexion of the 
toe may be the result of an instinctive effort to support 
the weak arch (hammer toe flat foot — Nicoladoni). In 
other instances hallux rigidus is caused directly by 
traumatism ; as by stubbing the toe, by kicking a hard 
object, or by other strain or injury. The affection ap- 
pears to be, primarily, a form of periarthritis, caused 
by injury or pressure. The restriction of motion is in 
part due to muscular spasm, and in part to the irrita- 
tive and accommodative changes in the ligaments and 
tendons. In more advanced cases changes in the car- 
tilage and shape of the articulating surfaces, due to dis- 
use of function, and to pressure and friction, may be 
present. 

Treatment. — If the rigid and painful joint is not 
associated with the weak arch, it may be relieved by 
providing the patient with a proper shoe, which ex- 
erts no pressure on the sensitive part. Motion of 
the joint may be lessened by increasing the thickness 
of the sole, or if necessary, it may be entirely restricted 
by the insertion of a brace of tempered steel between the two layers 
of the sole, as shown in the diagram. If, as in some instances, the 
rigid and flexed joint is associated with rigid flat foot, both defor- 
mities may be over-corrected, under anaesthesia, and retained in this 
position by the plaster bandage, as a preliminary treatment. 

If the milder type of painful joint is associated with the ordinary 
weak foot, the treatment of the latter condition will usually relieve the 
symptoms. In this class, particularly among the poorer patients, the 
shoe may be raised on the inner side, and the sole stiffened by means 
of the wedge-shaped sole recommended by Thomas, as already de- 
scribed in the treatment of the weak and flat foot. If painful motion 




The dotted out- 
Iine shows the 
shape of the steel 
spliut that may 
be inserted in the 
sole of the shoe for 
hallux rigidus. 



550 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



is restricted and the exciting causes of the disability are removed, re- 
lief of the symptoms is usually immediate. In the chronic cases, in 
which the pathological changes are more advanced, excision of the 
joint may be necessary. 

Painful Great Toe Joint in Older Subjects. 

A similar condition of the joint is sometimes found in older sub- 
jects. In many instances the foot is well formed, and the restriction 
of motion in the joint is very slight ; yet forced dorsal flexion causes 
pain and long standing or walking causes much discomfort, particu- 
larly a dull ache in the joint and sharp neuralgic pain referred to the 
terminal phalanx. In some cases, the onset of the symptoms may be 
ascribed to a long walk, or " mountain climb," in others to wearing 
tight shoes, and in some instances, no definite cause can be assigned by 
the patient. In such cases, the symptoms are often supposed to be 
evidences of gout or rheumatism but although the local discomfort may 

Fig. 376. 




Simple congenital varus, adduction without supination— a form of pigeon toe. 

be aggravated by a predisposition to such diseases, yet no relief can be 
obtained by medication unless it is combined with the local treatment 
that has been described in the preceding section. The relief afforded 
"by such treatment alone, proves, in many instances, that the affection 
is purely local in its character. (Fig. 375.) 

As has been mentioned, pain referred to this joint is a common symp- 
tom of the weak foot, and of the contracted foot as well. It is also 
-caused by simple pressure on the joint, and by the use of improper 
shoes which force the toes into the abducted position. 

Pain directly beneath the great toe, and sensitiveness to pressure 
about the sesamoid bones seem to indicate an inflammation of the ten- 



HALLUX VALGUS. 551 

don sheath or local periarthritis. If the discomfort is persistent, the 
sesamoid bones may be removed. As a rule, such symptoms occur 
only in combination with pain or deformity of the great toe joint. 

Hallux Varus. 

Adduction of the great toe is not infrequent in infancy, and it may 
be associated with a slight degree of varus deformity. (Fig. 376.) The 
peculiarity attracts the mother's attention because of the difficulty of 
drawing on the socks. In many instances the muscles seem abnormally 
developed, and the toe appears to be somewhat prehensile in its move- 
ments. 

Treatment. — The abnormal mobility may be checked by inclosing 
the toes with a narrow strip of adhesive plaster ; in any event the 
ordinary shoe may be depended upon to correct any residual deformity 
of this character. If the adducted toe is combined with varus, it repre- 
sents a slight degree of club foot that must be corrected in the ordinary 
manner. (See talipes.) 

Pigeon Toe. 

Congenital hallux varus forms one variety of what is known as 
pigeon toe, or the habitual turning in of the feet in walking. The 
inward rotation may be due also to bow legs, or it may be an effect 
of congenital talipes that remains after the cure of the deformity, or of 
the exceptional variety of coxa vara, in which the depressed necks of the 
femora are turned forward. In most instances pigeon toe in childhood is 
symptomatic of weakness either of the arch of the foot or of the knees 
(genu valgum). In such cases, it is a conservative effort of nature that 
serves to check further deformity, and it needs no treatment other than 
that which may be applied to the weakness of which it is a symptom. 

In the exceptional cases, in which the posture is not symptomatic of 
weakness or the effect of deformity, the sole of the shoe may «be raised 
slightly on the outer border. This will correct the attitude in the 
milder type, if combined with instruction and training. In rare in- 
stances, the in toeing seems to be caused by limitation of the range of 
outward rotation at the hip joints, a restriction that must be overcome 
by systematic stretching of the contracted parts. In these and in the 
more obstinate cases of the simple type apparatus may be applied, sim- 
ilar to that used in the after-treatment of congenital club foot, to hold 
the feet in the proper attitude. (Fig. 377.) It must be borne in mind 
that the proper attitude of the feet is one of parallelism, not of outward 
rotation, and that slight pigeon toe will as a rule correct itself as the 
child grows older. 

Hallux Valgus. 

Hallux valgus is a deformity in which the great toe is turned out- 
ward to an exaggerated degree. Outward deviation of the toe is so 
common, owing to the use of improper shoes, that it is not recognized 



552 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



f 



as a deformity, at least from the popular standpoint, unless the joint 
appears to be much " enlarged " forming a so-called bunion. 

Hallux valgus is practically a partial dislocation of the phalanx 
upon the metatarsal bone. In well-marked cases, the metatarsal bone 
is adducted or turned inward so that an abnormal interval separates its 
head from its fellows, while the phalanx is displaced outward and 

articulates only with the outer condyle. 

The angle thus formed, or more prop- 

terly the inner condyle of the adducted 
metatarsal bone, makes the prominent or 
"outgrown "joint. (Fig. 382.) This pro- 
jects sharply beneath the skin, and is ex- 
posed to injury and to the pressure of the 
shoe ; thus a bursa develops beneath the 
skin, while a corn or callus forms on its 
superficial surface. The projecting bone, 
covered by the irritated bursa and the 
thickened skin, makes up the bunion. 

In many instances the other toes are 
displaced outward, in the direction cor- 
responding to that of the great toe, or 
this may be rotated on its long axis and 
^■rali li^P y ie above or beneath its fellows. 

W ^^mb^ Pathology. — The pathological changes 

are such as usually follow deformity, dis- 
use of function, and injury. The car- 
tilage on the exposed condyle atrophies, 
the sesamoid bones, together with the 
flexor tendon, are displaced outward, the 
tissues on the outer side undergo accom- 
modative shortening, while those on the in- 
ner side are correspondingly lengthened 
and attenuated. The surface of the bone 
beneath the irritated periosteum is often 
roughened and irregular, and exostoses 
may form about the condyle, and thus ag- 
gravate the effects of the external pres- 




sure. 



An appliance constructed of 
leather bands and elastic webbing 
for the correction of in toeing. Name 
of the inventor unknown. 



Etiology. — The deformity is the direct 
effect of shoes that are too narrow and 
of improper shape, and in some instances 
too short for the foot, so that the great 
toe is subjected to lateral and longitudinal pressure. The deform- 
ing effect of the shoe is increased if the arch is weak, so that the 
toe is forced forward into the narrower part of the shoe when the 
foot is in use. The deformity may be increased by injury, or by the 
changes that follow gout, rheumatism, or rheumatoid arthritis, and 
in rare instances, the distortion may be the direct result of such dis- 



OPERATIVE TREATMENT. 553 

eases ; but all other factors are of slight importance when compared to 
the deforming influence of the ordinary shoe. The deformity begins 
at a very early age ; it advances more rapidly during adolescence, but 
the symptoms do not often become troublesome until later years. Both 
toes are affected, as a rule, although the deformity and its accompany- 
ing symptoms are usually more marked on one side. 

Symptoms. — As has been stated, the slighter grades of deformity 
are not recognized as such, and it is usually because of the pain due to 
the irritating corn or bursa, and incidentally, because of the outgrown 
joint, that the patients apply for treatment. 

Treatment. — The symptoms in the ordinary cases may be relieved 
by providing a proper shoe, by which pressure on the joint is com- 
pletely removed. (Figs. 361, 378.) The sole should be strong, and 
it should be slightly thicker along the inner side so that the sensitive 
joint may be inclined away from the upper leather. In cases in which 
the deformity is not far advanced, the use of a proper shoe that allows 
space for an improved position of the great toe, combined with method- 
ical manual correction of the deformity, and exercise of the disused 
muscles, while the toe is guided in the proper directions by the fingers, 
will relieve the symptoms promptly and practically cure the deformity. 

Several forms of correcting braces have been devised, to be worn 
during the day, a digitated stocking and special shoe being, of course, 
necessary. But in the class of cases that can be successfully treated 
by mechanical correction, few patients will be found who are suffi- 
ciently interested in the cure of the deformity to submit to the slight 
discomfort caused by a brace. 

A simple device for holding the toe in an improved position is the 
Holden toe post, recommended by Walsham and Hughes. This is a 
thin piece of metal so fixed in the front and inner side of the sole of 
the shoe that it separates the first and second toes from one another 
and holds the former in an improved position. It of course necessi- 
tates a special shoe and a special shoemaker to fit it in its proper place. 

Operative Treatment. — In cases in which the deformity is of long 
standing, and in which the projecting condyle or the exostoses make 
protection of the sensitive joint difficult an operation is indicated. The 
primary object of the operation is to remove the projecting bone. This 
may be accomplished by a slightly curved incision about the inner 
aspect of the condyle, the center being below the joint, so that the scar 
will not be subjected to pressure. The flap of skin is raised, the peri- 
osteum and part of the capsule are lifted from the bone, and the entire 
condyle is removed with a chisel, so that the surface is made perfectly 
smooth. Contracted tissues that resist a corrected position of the toe 
are stretched or divided, and the wound having been closed with 
sutures, a plaster bandage is applied about the foot and toe. This 
may be worn with advantage for several weeks, when the parts will 
have become less sensitive, and the toe will have become accustomed 
to an improved position. The after-treatment is the same that has 
been described for the ordinary cases. 



554 DISABILITIES AND DEFORMITIES OF THE FOOT. 

In most instances, it is well to remove the thickened bursa from 
beneath the flap of skin. As minor points in the operation, the re- 
moval of the displaced sesamoid bones has been advised • and the 
tendency to recurrence of deformity may be checked according to 
Weir/ by dividing the tendon of the extensor proprius pollicis, and 
sewing its proximal end to the periosteum of the inner border of the 
base of the first phalanx. 

Cuneiform osteotomy of the metatarsal bone is an effective operation 
if the base of the wedge includes the projecting bone. Resection of 
the head of the metatarsal bone is as a rule unnecessary, but it may be 
indicated if the deformity is extreme. 

Hallux valgus is often combined with the weak or broken-down 
arch ; in such cases the foot must be supported by a properly fitted 
brace. This is of especial importance after treatment by operation. 

Bunion. — As has been stated, the discomfort of hallux valgus is caused 
in great part by the irritated bursa and the over-lying corn. These 
symptoms may be relieved by rest and by hot applications. After- 
wards the callus or corn may be removed, and the sensitive bursa may 
be protected by a bunion plaster. Operative treatment should be de- 
ferred until after the acute symptoms have subsided. 

Hammer Toe. 

Hammer toe is a contraction of one of the toes, usually of the sec- 
ond, in which the first phalanx is dorsi-flexed, the second plantar 
flexed, while the third may be flexed or extended. The contracted toe 
is over-lapped by its fellows ; its projecting dorsal surface is subjected 
to the pressure of the upper leather of the shoe, and the terminal pha- 
lanx, forced against the sole of the shoe and compressed by the adjoin- 
ing toes, becomes flattened into a club or hammer-like form. The nail 
is distorted and often " ingrown "; in most cases a corn or callus 
forms upon the extremity of the toe and a small bursa and corn over 
the projecting knuckle, on the dorsal surface. A third corn or callus is 
often found beneath the head of the metatarsal bone which has been 
forced downward by the flexion of the toe. 

Hammer toe is usually bilateral ; it may be congenital, and heredi- 
tary even, but it is usually acquired, the effect of shoes that are too 
short and too narrow. The second toe is deformed most often because 
it is the longest, and because it suffers most from the lateral compres- 
sion as well. The deformity begins, as a rule, in early childhood, 
when, the growth of the foot being rapid, it is more likely to suffer 
from the effects of outgrown shoes, and socks as well. 

Symptoms. — The symptoms are practically those of the corns or 
blisters caused by the pressure of the shoe, but they are often suffi- 
ciently troublesome to interfere seriously, not only with the comfort 
but with the ability of the patient. 

Treatment. — The resistance to the rectification of the deformity is 

1 Annals of Surgery, April, 1897. 



DISPLACEMENT OF THE PERONEI TENDONS. 555 

caused by the accommodative changes that follow habitual malposition. 
In cases of long standing, all the tissues may be involved in the con- 
traction, of which the most resistant are the shortened capsular and 
lateral ligaments of the first inter-phalangeal joint. 

The congenital hammer toe of the infant may be treated by manipu- 
lation. When the resistance is overcome, the toe may be held in proper 
position by narrow strips of adhesive plaster passed over and under it 
and about its fellows. In older children a digitation in the stocking 
will often hold the toe in place if the deformity is slight and if a wide 
shoe is worn. In adult cases, in addition to the manipulation and shoe, 
a retention apparatus, in the form of a light plantar splint, or stiffened 
inner sole to which the toe can be attached, should be worn. If the 
deformity is more resistant, the toe may be straightened by force, aided, 
if necessary, by the subcutaneous division of the contracted ligaments ; 
but in advanced cases, the most effective treatment is resection of the 
joint. Sufficient bone should be removed to allow the correction of the 
deformity, or in case of its recurrence, to prevent the projection of 
the joint above its fellows. By this operation permanent relief may be 
assured. 

Over-lapping Toes. 

Over-lapping toes are very common among adults, owing to the 
pressure of the narrow shoe ; and not infrequently such deformity is 
seen in infancy and is apparently congenital. Deflected or deformed 
toes may be treated in infancy by manipulation, and by support with 
strips of adhesive plaster in the manner described. In childhood ex- 
ercise and proper shoes will usually correct acquired deformity. In 
older subjects, an inner sole somewhat like a sandal, to which the toes 
may be attached by bands of tape, may be employed if the deformity 
is considered by the patient of sufficient importance to demand treat- 
ment. 

Exostoses of the Foot. 

Simple exostoses of the foot, as distinct from those that are due to 
disease, as for example, to rheumatoid arthritis, are, in most instances, 
caused by the pressure upon a projecting bone of a somewhat deformed 
foot. The common examples are the hypertrophy of the scaphoid, 
often seen in flat foot of young children, the projection of the cunei- 
form bones on the dorsum of the hollow or contracted foot, the enlarge- 
ment of the internal condyle of the first metatarsal bone complicating 
hallux valgus and the exostoses of the os calcis in achillo-bursitis. As 
a rule, the treatment of the deformity of the foot and the removal of 
pressure will relieve the symptoms without other treatment. Operative 
removal may be required in exceptional cases. 

Displacement of the Peronei Tendons. 

Permanent displacement of these tendons forward of the malleolus, 
is not uncommon as a result of paralytic deformity, particularly ta- 



556 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



lipes calcaneus, and in such instances it gives rise to no symptoms. 
Displacement of one or both of the tendons, or rather a laxity of their 
attachments, that allows an occasional displacement or slipping from 
the groove behind the malleolus, may result in serious disability, be- 
cause of the pain that follows the displacement, and because of the 
weakness and insecurity, of which the patient usually complains. 

The cause of the laxity of the tissues that allows displacement in feet 
otherwise normal, may have been injury, but as the affection is often 
bilateral, the predisposition may be congenital. 

Treatment.- — If the displacement is recent, as when it follows injury, 
the tendons should be replaced and the foot should be fixed in a plas- 
ter bandage until repair has taken place. If the displacement is 
habitual, a brace may be applied to restrain those motions at the ankle 
that induce it. In the chronic cases, an operation with the aim of fix- 
ing the tendons by deepening the groove in the malleolus, or by sutur- 
ing the displaced sheath in its normal position, may be indicated. If 
on examination the cause of the* displacement appears to be a shorten- 
ing of the tendon, it may be divided and lengthened in the ordinary 
manner. (Fig. 241.) 

Shoes. 

The shoe, as a factor in the etiology of deformity and disability, has 
been mentioned several times in the preceding pages, but it is a subject 
of such importance that it would seem to call for special consideration. 

The object of the shoe is to cover and protect the foot, not to de- 
form it or to cause discomfort ; therefore, the one should corre- 



Fig. 379. 



Fig. 378. 





Normal feet. 



Proper soles for normal feet. 



spond to the shape of the other. If the feet are placed side by 
side, the outline and the imprint of the soles will correspond to the 
accompanying diagram. (Fig. 378.) The outline demonstrates the 
actual size and shape of the apposed feet, emphasized by enclosing 



SHOES. 



557 



them in straight lines. Thus, each foot appears to be somewhat trian- 
gular, being broad at the front and narrow at the heel. The imprint 
shows the area of bearing surface, and owing to the fact that but a 
small portion of the arched part of the foot rest's upon the ground, it 
appears to be markedly twisted inward. The sole of the shoe, if it is 
to enclose and support the bearing surface, must also appear to be 
twisted inward in an exaggerated right or left pattern. It will be 
straight along the inner border to follow the normal line of the great 
toe, and a wide outward sweep will be necessary in order to include the 
outline and thus to avoid compression of the outer border of the foot. 
(Fig. 379.) 

This demonstration of the true form of the foot is almost an indis- 
pensable preliminary. to an intelligent discussion of the relative merits 
of shoes, and indeed, it is somewhat of a revelation to those who have 
thought of the foot only as it has been subordinated to the arbitrary 
and conventional standard of the shoemaker. The ideal, or shoe- 
maker's foot, upon which lasts are fashioned, is much narrower than 
the actual foot ; the great toe is not a powerful movable member, pro- 
vided with active muscles, but is small and turns outward, so that the 
forefoot is somewhat pyramidal in form and turns upward as if to avoid 
the contact with the ground. This imaginary foot, drawn after the 
shape of the ordinary last, appears in the diagrams. (Figs. 380, 381.) 
Upon it the sole of the shoe 



Fig. 380. 



Fig. 381. 



has been indicated, to con- 
trast it with the shape of 
that necessary to include the 
outline of the normal foot. 
The actual foot is thus com- 
pressed laterally by the shoe 
until the stretching of the 
leather, during the " break- 
ing in " process, allows it 
to overhang the sole. The 
great toe is forced outward, 
and, with its fellows, is com- 
pressed, distorted, and lifted 
off the ground by the rocker- 
shaped sole (Fig. 383), so 
that normal function is re- 
duced to the smallest limit. 
Thus, the foot, according 
to the age at which the reshaping process is begun and the constancy 
of the application, gradually approaches the ideal and fits the shoe. 
(Fig. 382.) 

This remodelling, however, is often accompanied by such discomfort 
that the individual rebels and wears a shoe with a square toe, which, 
from the conventional standpoint, is supposed to show a meritorious 
effort to follow nature. But the demonstration of the actual foot makes 





Shoemaker's feet. 



Shoemaker's soles. 



558 



DISABILITIES AND DEFORMITIES OF THE FOOT. 



it evident that it is a properly shaped sole, which serves as a support, 
not the part which projects beyond the foot, that is of importance. If 
the shoe with the square toe is wider, and straighter on the inner side 
than another with a pointed toe, it is in so far an improvement. But, 
as a matter of fact, one of the worst types of shoe provided for chil- 
dren, in shape very like the old-fashioned coffin lid, owes its popularity 
to the square toe. The same comment may be made on the so-called 

Fig. 382. 




Skiagram of a foot modeled to fit the shoe, illustrating the 
etiology of hallux valgus. 

" common sense " shoe, which is well named, since it may be assumed 
that a properly shaped shoe is an evidence of uncommon sense. 

The object of the heel is to make walking easier by inclining the 
body somewhat forward. The high narrow heel is an insecure sup- 
port, and aids deformity by throwing more strain upon the forefoot 
and pushing it forward into the narrowest part of the shoe. The heel 
is of course unnecessary in childhood, and should not be worn, since it 



SHOES. 559 

limits the necessity for, and therefore the use of, the normal range of 
motion at the ankle joint. The ordinary shoe, by restricting the func- 
tional use of the foot, favors awkwardness and improper attitudes. It 
compresses the toes, and is directly responsible for corns, bunions, in- 
grown toenails, and deformities, and indirectly it causes or aggravates 
nearly every weakness to which the foot is liable. This assertion does 
not need support of argument, since in some degree it has been proved 
by the personal experience of every shoe wearer. 

The shape of the proper shoe corresponding to the undistorted foot 
has already been demonstrated. (Fig. 379.) The sole should be thick 
enough for protection, but not so rigid as to limit normal motion ; it 
should follow the imprint of the foot, projecting somewhat beyond the 
outline of the toes ; it should be flat (Fig. 384), and the upper leather 



Fig. 383. 





The rocker sole. The flat sole. 

should be capacious. In other words, the front of the shoe should be 
designed to allow and to encourage functional activity, the slight ad- 
duction of the great toe and the alternate expansion and contraction of 
its fellows, as may be observed in the barefoot child. Thus the arches 
may be supported, and the weight and strain properly distributed. The 
heel should be broad and low. Most adult feet are more or less de- 
formed, and therefore better suited by an improved than by a perfect 
shoe. Of this class, what is known as the wide Waukenphast pattern 
is the best. In selecting the better from the w r orst of the " ready 
made " shoes, the breadth of sole, the angle of outward deviation of 
the soles, when the two are placed side by side, and the capacity of the 
upper leather, must be the determining points. The most effective 
work for reform can be accomplished by providing proper shoes for 
children, and thus preventing deformity. The inspection of children's 
feet shows that atrophy and compression begin at a very early age, and 
if protection might be assured during the period of rapid growth, 
serious distortion might be prevented. 

Socks. — Although of far less importance than the shoes, the socks 
worn by children deserve special mention as a factor in deformity, 
since they are often too short and too narrow and are made of unyield- 
ing material, so that the proper action of the toes is restrained. Theo- 
retically, the socks, like the shoes, should be rights and lefts, but if 
they are sufficiently large and of a texture to expand readily to the 
shape of the foot, but little trouble need be anticipated on this score. 



CHAPTER XXII. 



DEFORMITIES OF THE FOOT. 



Fig. 385. 



Talipes. 

In the preceding chapters, the disabilities of the foot, of which the 
symptoms of pain and discomfort were of greater importance than 
actual deformity, have been described. One now passes to the con- 
sideration of the congenital and acquired disabilities, of which deformity 
is the most noticeable feature. 

Distortions of the foot are, practically, fixed positions in normal atti- 
tudes, or what are exaggerations of normal attitudes ; in other words 
the ordinary deformities can be voluntarily simulated and the centers 
of motion, at which the foot is deformed, are the centers of normal 

motion. If the foot has been 
fixed in the abnormal attitude 
during the process of formation 
and rapid growth, or if it has 
been used for any length of time 
in the abnormal position, the 
deformity becomes exaggerated 
beyond the possibility of imita- 
tion, and secondary variations 
in its shape, size and nutrition, 
follow. 

The deformities of the foot 
are grouped under the generic 
name of talipes, derived from 
talus (ankle) and pes (foot), 
signifying, therefore, a form of 
deformity in which the patient 
walks upon his ankles. Talipes 
was thus originally synonym- 
ous with the popular term club 
foot, but at the present time it 
is used simply as a prefix to the 
descriptive titles of the different 
distortions, while club foot is 
usually applied only to the most 
common of the congenital de- 
formities, equino-varus, in which the distorted foot is club-like in form. 
Varieties. — There are four simple varieties of the distorted foot or 
talipes : 




Paralytic equinus. Recovery from paralysis, but 
deformity persists. 



TALIPES. 



561 



1. Talipes equinus, the extended or plantar flexed foot. In well- 
marked cases the patient walks upon the heads of the metatarsal bones, 
an attitude that suggested the name equinus (horse-like). 

2. Talipes calcaneus, the dorsi-flexed foot in which the heel is 
prominent, and which alone bears the weight in walking ; hence, cal- 
caneus from calcaneum, the heel bone. 

In these forms the center of motion is at the ankle joint. Under 
the terms equinus and calcaneus, are included not only the cases of 
marked deformity, but also those in which the range of dorsal or plan- 

Fig. 386. 




Congenital calcaneus. In this form the arch is obliterated. In the acquired 
form if is increased. 



tar flexion is sufficiently limited as to cause a change in the contour of 
the foot. 

3. Talipes varus, the inverted foot. In this deformity the foot is 
turned in or adducted, and combined with the inward twist there is al- 
ways a certain amount of supination, or inversion, that is, the inner 
border of the sole is elevated and the outer border is depressed, so that 
the weight falls to the outer side of the center of the foot. 

4. Talipes valgus, the everted foot. This deformity is the reverse 
of varus. The foot is abducted and pronated, so that, in use, the 
weight falls on the inner border. 

In these forms of lateral deformity, the center of motion is at the 
medio-tarsal and sub-astragaloid joints. 
36 



562 



DEFORMITIES OF THE FOOT. 



These simple deformities in which the foot is persistently extended 
or flexed, or twisted in or out, are comparatively uncommon. 

Compound Deformities. — As a rule the deformities are combined in 
varying degree, thus the over-extended or the over-flexed foot is 
usually twisted inward or outward, making four varieties of compound 
deformity. 

1. Talipes equino- varus, the extended and inverted foot. 

2. Talipes equino-valgus, the extended and everted foot. 

3. Talipes calcaneo- varus, the flexed and inverted foot. 

4. Talipes calcaneo-valgus, the flexed and everted foot. 

In these more important deformities, the arch of the foot may be in- 
creased or diminished in depth. It is, for example, usually increased 
in calcaneus and equinus, and it is usually diminished in valgus ; but 
this secondary or subordinate deformity is not recognized in the ordinary 
classification. If the arch of the foot is simply exaggerated, the con- 
dition is sometimes called pes cavus ; if it is lessened or lost, it is called 
pes planus. These slight degrees of distortion, in which the func- 
tional disability is usually more important than the deformity, are 
rarely classed as forms of talipes. Simple cavus, the hollow or con- 
tracted foot ; and pes planus, one of the forms of the common weak 
or flat foot, have been described elsewhere. (Chapters XXI., XXII.) 

Etiology. — From the rem- 
Fig. 387. edial standpoint, the cause of 

the deformity is of far greater 
importance than its form. Thus 
one divides the distortions of 
the foot into two groups. 

1. The congenital form, 
in which the foot, in process of 
formation, has slowly grown 
into deformity before birth. 

2. The acquired form, in 
which the foot, perfect at birth, 
has at a later time become dis- 
torted. 

The congenital club foot may 
be considered simply as a twist- 
ed foot, of which the component 
parts, although distorted to a 
greater or less degree, are capable of regaining perfect form and function. 
This is practically true of the great majority of cases, although there are 
instances in which congenital deformity is complicated by defective for- 
mation of the foot or leg, or in which the deformity is caused by, or 
at least accompanied by, paralysis ; as for example, in certain forms of 
spina bifida or other defect or disease of the nervous apparatus. 

The acquired deformity is nearly always a consequence of paralysis 
of spinal origin (anterior poliomyelitis). Certain muscles, or groups 
of muscles being paralyzed, usually in early childhood, the muscular 




Congenital valgus. 



ETIOLOGY OF CONGENITAL TALIPES. 



563 



force of the foot is unbalanced and it is drawn into a distorted position 
by the contraction of the unopposed muscles, and by the influence of 
gravity. This distortion is confirmed and increased by the accom- 
modative changes in the structure that accompany functional use and 
growth in the abnormal attitude. 

Far less often, acquired talipes may be the result of paralysis of 
cerebral origin, of other forms of spinal disease ; of local paralysis fol- 
lowing neuritis or injury to a 

nerve trunk. It may be caused F IG# 388. 

by scar contraction, as after a 
severe burn, or by direct in- 
j ury to the bone, or by disease 
that may interfere with sub- 
sequent growth. (Fig. 236.) 
Such are, however, extremely 
uncommon causes, so that the 
statement holds good that the 
congenital club foot is a simple 
distortion capable of perfect 
cure. Acquired club foot on 
the other hand is a deformity 
and disability usually second- 
ary to disease of the spinal 
cord ; it is therefore capable 
only of rectification and not of 
perfect cure, unless recovery 
from the original disease, of 
which it is a result, has taken 
place. 

Etiology of Congenital Tali- 
pes. — As of other congenital 
deformities, the etiology of 
talipes is more or less conjec- 
tural. Occasionally, the in- 
fluence of inheritance is ap- 
parent, and again, two or more 
children with club foot may be 
born of the same mother, but, 
as a rule, nothing in the family 
or personal history will be 
found that may in any manner explain the deformity. The most rea- 
sonable explanation as applied to the majority of cases, is the mechan- 
ical. This is, in brief, the theory that the foot has from some cause 
remained for a longer or shorter time in a constrained or fixed position, 
and has thus grown into deformity. 

It has been claimed by Eschricht, and also by Berg, 1 that at about 
the third month of intra-uterine life the thighs of the embryo are ab- 
] Berg, Archives of Medicine, N. Y., Dec. 1, 1882. 




Congenital club hands and feet, combined with 
anchylosis of nearly all the joints. (Compare with 
Fig. 389.) 



564 



DEFORMITIES OF THE FOOT 



ducted, flexed and rotated outward, the legs are crossed and the feet 
are plantar flexed and adducted so that the inner surfaces of the thighs, 
the tibial borders of the legs and the plantar surfaces of the feet, are 
held in close apposition to the abdomen and to the pelvis of the fetus. 
Later, there is an inward rotation of the legs so that the feet are 
turned gradually outward until the soles are brought into contact with 
the uterine wall, the feet then being in the attitude of abduction and 
dorsal flexion. According to this theory, there is a regular succession 
of attitudes during intra-uterine life. If the inward rotation of the 
lower extremity is prevented, or if it is incomplete, the foot remaining 

Fig. 389. 




The etiology of congenital club hands, club foot and anchylosis of the joints. The habitual attitude 
at birth. Photograph at age of three months. (See Fig. 388.) 

in the original position, becomes deformed. Thus equino-varus being 
the normal attitude of the early and middle period of intra-uterine life, 
is not only the most common, but it is the most intractable of the con- 
genital deformities. But if the constraint or pressure is not exerted 
until a later period, after rotation has taken place, when the foot has 
attained or nearly attained its normal size and shape, it will then in- 
duce the rarer and comparatively slight grades of deformity, such as 
calcaneus or valgus. 

This theory, which seems interesting and reasonable, appearsto rest 
on a very insecure basis. Bessel Hagen states that in embryos of 30 



ETIOLOGY OF CONGENITAL TALIPES. 



565 



mm. in length, the foot is in extreme plantar flexion ; in those of 90 
to 100 mm., the foot is at a right angle to the leg ; and from this size 
to that at full term, the foot may be found in any position, abducted, 
adducted or dorsi-flexed. He states also that supination is not the 
usual attitude at an early period but is more common near the termi- 
nation of intra-uterine life, and when it is present it is more often 
combined with dorsi-nexion. In other words, there is no time when 
the foot regularly and normally assumes the attitude of club foot, from 
which it is changed by the rotation of the legs. Scudder l after simi- 

Fig. 390. 




Intra-uterine " amputations." The patieut is a tailor. 

lar investigations, arrived at practically the same conclusions. He 
states that there is no necessary relation between the age, the rotation 
of the legs and the position of the feet. 

Although the rotation theory may not be accepted, still it would ap- 
pear that there is, during the process of development, a more or less 
regular change in the attitudes of the limbs and feet. If they are fixed 
in one position during this period of rapid growth, distortion must 
follow ; if the constraint is slight and if its influence is exerted at a late 
period, the deformity will be slight ; if it occurs at an early period, the 
deformity will be more resistant. 

One of the causes of constraint, and thus of ultimate deformity, ap- 
pears to be the interlocking of the feet. Many museum specimens 
show this, and in some of the cases of talipes seen during the first week 
of life, the feet may be replaced in the attitude in which they had been 
Boston Med. and Surg. Jour., Oct. 27, 1887. 



566 



DEFORMITIES OF THE FOOT 



fixed before birth. (Fig. 306.) Intra-uterine pressure, although not 
usually the direct cause of club foot, undoubtedly has an influence in 
aggravating the deformity. The effect of pressure is not infrequently 
shown in atrophic areas of skin ; and bursa? even are sometimes found 
over prominent bones. Entanglement in the umbilical cord, the direct 
pressure of intra- or extra-uterine tumors, and the like, may be men- 
tioned also as possible causes. 

Evidence of restraint and of abnormal attitudes of the limbs, is seen 
not infrequently in connection with club foot ; for example, in hyper- 
extension or fixed flexion of the knees, and in cases of extreme de- 
formity, the foot is often smaller than normal, and otherwise asymmet- 
rical. The distorted foot may be imperfect in structure ; toes may be 
absent, " spontaneous amputation " (Fig. 390) or constricting bands 
about the leg or foot may be present. Such abnormalities are usually 
ascribed to amniotic adhesions. Talipes may be combined with evi- 
dences of impaired or arrested development ; with hare lip, extrophy 
of the bladder, spina bifida, and absence of patellae ; or with other de- 
formities such as club hand and wry neck. Or there may be evidence 
of intra-uterine disease, as in anchylosis of joints (Fig. 388) or so- 
called foetal rickets. Finally, deformities of the foot may accompany 
or are caused by absence of bones, as of those of the foot ; or other 
deformities and malformations, showing evidently an abnormality in 
the original make-up of the germ. This latter group, which includes 
the complications of club foot and imperfection of structure, is com- 
paratively small, and, as has been already stated, in the great majority of 
cases, congenital club foot is a simple deformity capable of perfect cure. 

Statistics. — The most accurate statistics are those compiled from the 
records of the Hospital for Ruptured and Crippled by Townsend. 1 
These have been supplemented for me by the later investigations of 
Dr. N. B. Waller. In the combined statistics are included the data 
of 3,453 individual cases of talipes. Of these 1,650 were congenital, 
and 1,803 were acquired. The relative frequency of the congenital 
and acquired forms of talipes has given rise to much discussion in the 
past, and statistics on this point are at considerable variance with one 
another. This may be explained by the fact that acquired talipes is, 
as a rule, a preventable deformity. At the present time, the extreme 
degrees of acquired talipes are comparatively rare, and the deformity is 
usually of a much slighter grade than the corresponding form of con- 
genital distortion. 



Sex of Congenital Talipes. 





Males. 


Females. 


Total. 




567 
498 


348 
237 


915 


Waller 


735 






Total 


1065 
64.5% 


585 
35.5% 


1650 


Percentage 





A Statistical Paper on Club Foot, Trans, of the Med. Society of N. Y., 1890. 



STATISTICS. 



567 





Sex of Acquired Talipes. 








Males. 


Females. 


Total. 




460 
515 


429 
399 


889 


Waller 


914 








Total 


975 


828 
45.8% 


1803 


Percentage 


54.1% 





Congenital talipes is much more common among males than among 
females. All statistics are in accord upon this point. Acquired talipes 
is more equally divided between the sexes. 



Foot Affected in Congenital Talipes. 





Eight. 


Left. 


Both. 


Total. 




274 

236 


256 
184 


385 
325 


915 


Waller 


745 






Total 


510 

30.7% 


440 

26.5% 


710 

42.7% 


1660 


Percentage 





Bilateral 710, 42.7%, 



Foot Affected in Acquired Talipes. 





Right. 


Left. 


Both. 


Total. 


IWnsend 

Waller 


384 
397 


347 
421 


158 
96 


889 
914 






Total 


781 
43.3% 


768 

42.6% 


254 
14.1% 


1803 


Pecentage 





Unilateral 1,549, 85.! 



Bilateral 254, 14.1 



In congenital talipes the deformity is nearly as often of both as of 

one foot, while in the acquired form, unilateral deformity is far more 

common. In each variety the right foot appears to be more often 
affected than the left. 

The Relative Frequency of the Different Forms of Congenital 

Talipes. 



Equino-varus 

Valgus 

Varus 

Calcaneo-valgus 

Equinus 

Calcaneus 

Equino-valgus 

Calcaneo-varus 

Cavus 

Valgo-cavus 

Equino-cavus 

Different deformity in each foot 

Total 



Town send. 


Waller. 


Total. 


667 


605 


1272 


87 


36 


123 


70 


15 


85 


15 


37 


52 


35 


5 


40 


11 


17 


28 


14 


14 


28 


4 


3 


7 


1 


4 


5 


1 





1 


1 





1 


9 


9 


18 


915 


745 


1660 



Percentage. 



77.0 
7.4 
5.1 
3.1 
2.4 
1.7 
1.7 



568 



DEFORMITIES OF THE FOOT. 



Eelative Frequency of the Different Forms of Acquired Talipes 
Together with the Etiology. 



Equino-varus 479 

Equinus 321 

Calcaneus 219 

Valgus 134 

Equino-valgus 114 

Calcaneo-valgus 76 

Varus j 41 

Calcaneo-cavus 12 

Equino-cavus 22 



Spinal. 



Ante- 
rior po- 
liomy- 
elitis. 



Cerebral. 



Hemi- 
plegia. 



Calcaneo- varus 

Cavus 

Varo-cavus. 



11 
35 

1 



28 
66 
3 
4 


2 




1 
1 



Para- 
plegia. 



35 

46 
1 
7 
5 

1 








Other 
forms 
of par- 
alysis. 



Trau- 
matic. 



29 

26 

1 

27 
3 
2 
5 

2 






Total. 



575 

462 

224 

173 

122 

78 

49 

12 

24 

11 

36 

2 



Per- 
centage. 



32.5 

26.1 

12.6 

9.7 

6.9 
4.4 

2.7 

1.3 

2.0 



1465 105 95 8 | 95 1768 

Deformity different on each side 50 

Anterior poliomyelitis 1465, 82.8%. Cerebral 200, 11.3%. Traumatic 95, 5.3%. 



Comparative Frequency of the Different Forms of Talipes, 
Congenital and Acquired. 

Congenital. Acquired. 

Equino-varus 77 per cent. 32.5 per cent. 

Valgus 7.4 " " 9.7 

Varus 5.1 •' " 2.7 

Calcaneo-valgus 3 1 " i; 4.4 

Equinus 24" " 26.1 

Calcaneus 1.7" " 12.6 



It will be noted that in three-fourths of the congenital cases the de- 
formity is equino-varus, and that equinus and calcaneus, rare as con- 
genital deformities, comprise 38 per cent, of the acquired forms. 

Occasionally the deformity is different on each foot, far more often 
in the acquired than in the congenital form (50 of the former or 19 per 
cent, of the 254 acquired bilateral deformities, as compared with 18 or 
less than 3 per cent, of the bilateral congenital). In 7 of the 18 con- 
genital cases, the deformity was equino-varus on one side, calcaneus on 
the other ; in 3 equino-varus and calcaneo-valgus, and in 3 simple 
varus and valgus. The 50 cases of acquired talipes represented every 
combination of deformity. 

In 31, or 4 per cent., of the 735 cases of congenital talipes in Wal- 
ler's table, the distortion was combined with other congenital defects 
or deformities, viz.: In 12 cases with double club hands; in 6 cases 
with defective development of the hands, webbed fingers and the like ; 
in 7 cases with spina bifida ; in 3 cases with absence of one or more 
bones of the leg ; in 1 case with torticollis ; in 1 case with hare lip ; 
in 1 case with dislocation of the knee and anchylosis of an elbow ; in 
2 cases with general rigidity and deformity of the joints. 



THE ANATOMY OF CONGENITAL CLUB FOOT 



569 



The Anatomy of Congenital Club Foot. Talipes Equino- varus. — 
Congenital talipes is, in the great majority of cases, the form in which 
the foot is twisted inward and downward, so that in extreme cases it 
resembles the club-like extremity that has received the popular name 
of club foot. The ordinary congenital club foot, in early infancy, is 
simply a foot held in an exaggerated attitude of plantar flexion, ad- 
duction and supination. The dorsum of the foot looks forward and 
slightly outward and upward, the plantar surface is abnormally con- 
cave and looks backward, inward and downward. The foot often 
seems somewhat smaller than normal and the heel appears to be ill 
formed. Upon the outer dorsal surface the prominence of the astra- 

Fig. 391. 




Congenital talipes equino-varus (club foot). 

galus and os calcis may be felt beneath the skin, the external malleolus 
is prominent, while the internal malleolus lies deep beneath the redun- 
dant tissues of the internal aspect of the foot. 

The internal structure of the foot is rearranged to correspond to the 
external contour ; thus the relation of the bones to one another, and 
the shape of the individual bones even, are more or less altered as the 
deformity is more or less of an exaggeration of the attitudes that the 
normal foot is capable of assuming. These changes are most marked 
in the astragalus and os calcis. The astragalus is somewhat wedge- 
shaped from without inward ; it is plantar flexed so that a large part of 
its body protrudes from between the malleoli. Its neck is often some- 



570 



DEFORMITIES OF THE FOOT. 




what longer than normal, and it is, as a rule, depressed and deflected 
inward. (Fig. 392, B.) The os calcis is also in an attitude of plantar 
flexion ; the internal tuberosity is drawn upward to the vicinity of the 
internal malleolus, its anterior extremity looks downward and inward, 
and it is often deflected inward corresponding to the deformity of the 
neck of the astragalus. Its external surface looks downward and for- 
ward, and it lies directly beneath the astragalus, instead of to its outer 
side, as in the normal relation. 

The scaphoid bone is drawn inward and upward, and articulates with 
the inner part of the deflected head of the astragalus ; it lies in close 
proximity to, and often articulates with, the internal malleolus ; the 
cuboid is displaced upward and inward, and lies to the inner side of 
the anterior extremity of the os calcis. The remaining bones are 
changed in position, but not materially in shape. In many instances 
the tibia is rotated inward upon the femur, and this inward rotation of 

the leg may persist after the 
Fig. 392. deformity of the foot has been 

corrected ; and in other cases 
there is often a moderate de- 
gree of knock knee and laxity 
of the ligaments. Less often, 
the tibia is slightly twisted 
inward on its long axis. 

The ligaments are altered 
to correspond to the changed 
relations of the bones. Those 
on the short side are more or 
less resistant, according to the 
duration of the deformity. 
The muscles are normal as 
to their structure and their 
origin and insertion, but the 
direction of the tendons as they pass across the foot, is altered some- 
what. Those attached to the inverted side, the extensor and adductor 
group, are shortened and are relatively stronger than those on the outer 
side, which are lengthened and atrophied from disuse. 

To sum up : all the component parts of the foot participate in the 
deformity. The most noticeable changes in the bones are in their 
position and relation to one another, but the astragalus, os calcis, and 
scaphoid bones are somewhat abnormal in shape as well. 

The most resistant structures in the deformed foot are the plantar 
fascia and the ligaments that bind the scaphoid, the os calcis and the 
internal malleolus to one another. The muscles that are most active 
in retaining and increasing the deformity are the tibialis anticus, the 
tibialis posticus, and the combined gastrocnemius and soleus. 

The changes that have been outlined, which are comparatively slight 
and which may be easily rectified soon after birth, become more 
marked as the part develops. And when the child begins to walk, the 






The deformities of the astragalus in club foot (Adams). 
A, Astragalus of a normal infant ; 1, from above ; 2, from 
within ; 3, from without. B, The astralagus in clubfoot 
in the same positions. 



THE ANATOMY OF CONGENITAL CLUB FOOT. 



571 



weight of the body, combined with growth and functional use in the 
abnormal position, increases and fixes the deformity. 

In the adolescent or adult type of club foot that has remained un- 
treated, the deformity is so extreme that the patient actually appears 
to walk on the outside of his ankles, as the term talipes implies. The 
feet turn directly inward, or even inward, upward and backward, and 
the peculiar walk, by which interference of inverted feet is avoided, 
has given another name (reel foot) 
to the deformity. 

In such cases, knock knee is 
usually well marked. This, al- 
though it may be present at birth, 
is usually a secondary distortion 
caused in great part by the accom- 
modation to the deformity, that is, 
by the diminution of the base of 
support and by the interference of 
the feet. (Fig. 396.) 

The legs are shrunken from dis- 
use. Over the outer border of the 
foot, in the neighborhood of the cal- 
caneocuboid articulation, there is a 
large callus with an underlying 
bursa. The foot itself is atrophied 
and is much smaller than the nor- 
mal. The changes in the bones are 
much more marked ; only a small 
part of the articulating surface of 
the astragalus lies between the 
malleoli, and this posterior ex- 
tremity is flattened out to the 
shape of a wedge. There is con- 
sequently backward displacement 
of the leg bones, which is most 
apparent in the position of the ex- 
ternal malleolus. In fact, the 
changes in the foot may be so 
great as to make the component 
parts almost unrecognizable. (Figs. 391, 392, 393.) All the bones of 
the foot are more or less atrophied, and the normal area of cartilage 
has, to a great extent, disappeared from the proper articular surfaces. 

In this advanced stage, the normal muscular activity of the foot has 
disappeared. It is practically a simple rigid support, to which the 
patient has been so long accustomed that he may walk with compara- 
tive ease and with no discomfort, other than that caused by the corns 
and bunions at the pressure points. In these extreme cases, cure, in 
the sense of perfect functional recovery, is of course out of the ques- 
tion. But relief of the deformity, that is, replacement of the foot in the 




Talipes equino-varus in adolescence, showing the 
displacement of the astragalus and its relation to 
the scaphoid, also the atrophy and distortion of the 
bones of the leg. 



572 



DEFORMITIES OF THE FOOT. 



axis of the leg, at a right angle to it and in the plantigrade attitude, is 
nearly always possible. 

Symptoms. — The symptoms of congenital club foot have been, to 
all intents, included in the description of the deformity. The func- 
tional disability is of course considerable, although some patients are 
surprisingly active and are able to walk long distances. Discomfort 
from club foot is due almost entirely to the corns or inflamed bursse 



Fig. 394. 



Fig. 395. 





The tendons on the front of the foot. 



Talipc 



equino-varus. 

Showing the tendons in the sole of the foot and 
the extreme, displacement of the os calcis. 

over the bony prominences, and its degree depends of course upon the 
use to which the foot is subjected. 

Treatment. — In considering the treatment of congenital club foot 
it is customary to divide it into several classes corresponding to the 
degree of resistant deformity. 

The first class would include the very slight or non-resistant cases 
in which the deformity may be almost entirely corrected by slight 
manual force. 

The second class comprises those cases in which a certain amount 
of varus and well-marked equinus remain, which it is impossible to 
overcome by manipulation. 



TREATMENT. 573 

The first and second classes include the forms of infantile club foot. 

The third class comprises the cases of more extreme deformity, and 
those in which the resistance to the correction is great, as in many of 
the cases in early childhood, or those of later years that have been in- 
efficiently treated. 

A fourth class would include the untreated cases in the adolescent 
or adult. 

Congenital club foot (talipes equino-varus) treated at the proper 
time, that is to say, in early infancy, and in a proper manner, in the 
great majority of cases may be perfectly cured both as to form and 
function. 

Club foot in the adult may be made straight, but perfect functional 
cure is, of course, impossible. 

The club foot in childhood, in which treatment has been delayed, or 
in which it has been ineffective, may be cured as to form or function, 
but the effect of the distortion remains in a certain amount of atrophy 
of the foot and leg, caused by the long disuse of proper function. 

Although congenital club foot is an eminently curable deformity, yet 
perfect and permanent cure often requires minute attention to details 
during the active stage of treatment, supplemented by long-continued 
and careful supervision after the cure is supposed to be complete. No 
other deformity presents such a record of failures and incomplete cures, 
of relapses after apparent cure, of tedious and ineffective treatment by 
braces, often for many years, and of unnecessary and mutilating oper- 
ations. Some of the failures may be explained by the neglect of the 
parents, or by want of opportunity. A few are due to the unusual 
obstacles in the deformity itself, but by far the greater number must 
be accounted for by failure of the physician to apprehend the true 
nature of the deformity, or by his inexperience in the practical details 
of treatment. 

Principles of Treatment of Infantile Club Foot. — The infantile club 
foot is, as has been stated, simply a twisted foot. It is true that there 
are slight changes in the bones ; but the bones of an infant's foot are 
represented by yielding cartilage, which will rapidly reform under 
changed conditions. The ligaments, which are accommodated to the 
deformity may be easily stretched, together with the more resistant 
muscles and their tendonous insertions, and when the proper relation of 
the bones to one another has been restored the joints will become normal. 

The treatment of club foot may then be divided into three stages : 

1. The rectification of the external deformity. 

2. The support of the foot in proper position during the process 
of transformation of its internal structure and until the normal mus- 
cular power, unbalanced by the deformity, has been regained. 

3. The period of supervision. This would include the treatment of 
possible complicating deformities of the knee, the laxity of ligaments 
and the like, as well as the over-sight of the functional use of the foot 
and the leg, during the early years of life. 

On examining the infantile club foot one will notice the same mus- 



574 



DEFORMITIES OF THE FOOT. 



cular activity that characterizes the normal foot. The normal infant 
moves the foot in various directions, in a more or less regular alterna- 
tion of postures, but in the club foot, motion is in one direction only, 
that toward which the foot is turned. The muscles on the back and 
inner side of the leg, which are alone active, become relatively irritable 
and hypertrophied as compared with those on the front and outer side, 
that are disused. Thus, muscular activity of the deformed foot is in 
reality harmful, because it increases deformity and still further disturbs 
the muscular balance. For this reason the temporary restraint of 
motion, necessary during the rectification of the deformity, may be 
considered rather of advantage than otherwise. When movement is 
again allowed and encouraged, it must be in the directions opposed to 
the attitudes of deformity, with the aim of so strengthening the weak- 
ened group of muscles at the expense of the stronger, that the balance 
of muscular power may be reestablished. 

The First Stage of Treatment — Rectification of Deformity. — It should 
be stated at once, that " rectification of deformity " does not mean ap- 
parent symmetry, a misapprehension to which the majority of failures 
in treatment may be ascribed. It means, that when deformity is really 
rectified, all contracted and resistant parts must have been so elongated, 
that every passive motion and attitude possible for the normal foot, is 
equally possible and as easily attained in that which was deformed. 
This is actual functional rectification, as opposed to the simple straight- 
ening of deformity. 

The most important part of the club foot deformity is varus. The 
foot that is rolled over and twisted inward to the attitude of extreme 
adduction (Fig. 391), must be untwisted and forced into an attitude of 
extreme abduction or valgus, the so-called over-correction. (Fig. 387.) 
Until this is accomplished no attention whatever need be paid to the 
residual equinus. There are two reasons for dividing the procedure 
into two parts : First, in order that the attention of the surgeon may 
be concentrated on one and the most important part of the deformity. 
Second, because* by this preliminary untwisting, the os calcis is brought 
into the upright position, into its proper relation to the astragalus, to 
the bones of the leg and to the tendo Achillis, so that the true degree 
of equinus may be appreciated. 

Preliminary Manipulation. — As a rule, the second or third week of 
life is as early as mechanical treatment can be undertaken. Until then 
preliminary manipulation by the nurse, more particularly manual recti- 
fication of the deformity by gently drawing the foot toward abduction 
and retaining it in the improved position for a few minutes, as often as 
is possible, may be of service in overcoming its resistance. As a treat- 
ment by itself, however, simple manual rectification is tedious and in- 
effective, although partial cures have been attained by perseverance in 
this means alone. 

Mechanical Treatment. — Mechanical rectification is the treatment of 
choice and routine in infantile club foot. Of this treatment two methods 
may be described. 



MECHANICAL TREATMENT. 



o/o 



1. By the plaster bandage. 

2. By some form of simple splint. 

The principle of the two is essentially the same. The foot is drawn 
toward an improved position and retained there by the plaster bandage, 
or it may be fixed to some form of metal splint or brace whose shape 
is gradually changed from week to week, as the resistance lessens. 

Gradual Rectification of Deformity by means of the Plaster Bandage. — 
In this treatment care should be taken to avoid undue pressure, irrita- 
tion of the skin or insecurity of the bandage. One should place shreds 
of absorbent cotton between the toes ; and the outer aspect of the 
ankle, where the skin is thrown into folds when the foot is straight- 
ened, should be smeared with 

vaseline. A narrow strip of p IG 395 

adhesive plaster long enough 
to reach from the knee to a 
point an inch or more below 
the heel, is applied to the 
outer side of the leg. A thin 
layer of absorbent cotton is 
wound about the leg, just 
below the kuee, in order to 
protect the skin from the 
hard margin of the plaster 
bandage, and a similar strip 
is carried about the toes. The 
foot is then drawn gently 
toward the abducted position, 
otten as far as the axis of the 
leg, at the first dressiug, 
without causing discomfort. 
While it is held in this atti- 
tude, a narrow flannel band- 
age is smoothly applied to 
the leg and foot, the band 
of adhesive plaster being 
drawn out between the folds 

about the ankle. A very light plaster bandage is then applied, 
from the knee to the extremities of the toes, and into this bandage the 
projecting strip of adhesive plaster is incorporated, so that no dis- 
placement of the dressing is possible. The turns of both the plaster 
and the flannel bandage are made from within, downward and out- 
ward, so that the tension aids in retaining the foot. When the plaster 
bandage, which during the hardening process has been constantly 
rubbed and manipulated so that it may fit the part perfectly, has be- 
come firm, a long stocking is drawn over it and is attached to the body 
clothing. At the end of a week the bandage is removed. The leg 
and foot are gently bathed with alcohol, thoroughly dried, powdered 
and protected as before, and the bandage is again applied. At this 




Neglected club foot, showing the secondary knock knee. 



576 



DEFORMITIES OF THE FOOT. 



second dressing, the irritable adducting muscles, after the interval of 
complete rest, will be much less active and the contracted tissues will 
be less resistant, so that the foot may be easily turned somewhat out- 
ward, or beyond the line of the leg. 

After four or five applications of the bandage, at weekly intervals, 
the foot, in ordinary cases, can be held without resistance in the attitude 
of extreme equino-valgus. The sole, which at first looked backward, 
inward and upward will be turned in the opposite direction, forward, 
outward and downward, and the inner border of the foot, which was con- 
cave, is now convex. (Fig. 387.) When the varus has thus been over- 
corrected, treatment is directed to the secondary equinus. At this stage 

Fro. 397. 




The first application of the plaster bandage, showing the improved position. (Compare with Fig. 391. ) 

it is well to cover the bottom of the foot with a foot plate of thin wood 
(splint wood or cigar box cover) to give the plaster bandage more solidity, 
and in order that its pressure may aid in flattening the rounded sole. 
At first, one carries the foot upward (toward dorsal flexion) while it is 
still retained in the abducted position, but when the right-angled attitude 
has been attained, it is brought nearer to the axis of the leg. The 
everted position, or the attitude opposed to varus, is retained however, 
until correction is completed. In correcting the equinus a certain 
amount of force is required, sufficient to cause some discomfort during 
the application of the plaster, but not sufficient to cause suffering after- 
wards. The force is applied by means of the sole plate to the entire 



MECHANICAL TREATMENT. 577 

foot, so that the posterior extremity of the os calcis may be drawn down- 
ward by actual lengthening of the tendo Achillis, and not, as is often 
the case, by an over-correction of the forefoot, while the heel remains 
in its original position of plantar flexion. By the proper application of 
force the eqninus is gradually overcome ; the sharp indentation or fold 
at the insertion of the tendo Achillis is lessened, and the heel becomes 
more prominent. 

The reduction of the equinus may be somewhat more difficult than 
that of the varus, but it should be entirely corrected in three or four 
months from the time of beginning the treatment. 

As has been stated, correction of the deformity implies over-correction. 
(Fig. 386.) And it is well, when this has been attained, to hold the foot 
for several weeks, by means of the plaster bandage, in an attitude of 
extreme pronation and dorsal flexion (calcaneo-valgus) in order to im- 
press, as it were, the new position upon its structure. This concludes 
the first stage of the treatment, the simple rectification of deformity. 

Correction by the plaster bandage has the great advantage of plac- 
ing the treatment entirely under the command of the surgeon. Prop- 
erly applied, the support is perfectly fitting and it holds the foot in the 
desired attitude without undue pressure. 

The disadvantages of the treatment are almost entirely due to its 
improper application. For instance, the bandage may be too heavy, 
or the padding may be so thick that it does not retain its position. 
Excoriations are usually due to carelessness in the application of the 
bandage, or because it is not removed in proper season. The fear of 
compression, of atrophy of muscles, of stunting the growth of the 
limb, is groundless. At the end of the plaster of Paris treatment, the 
corrected foot is, as a rule, larger than one that has remained untreated. 
The stunted foot is the result of non-treatment, or of ineffective treat- 
ment by braces or otherwise ; not of the enforced rest necessitated by 
the proper reduction of deformity. 

The Rectification of Deformity by Splints and Braces. — Of* mechan- 
ical supports, there are many varieties. Complicated appliances should be 
avoided because they are unnecessary, and because they serve to distract 
attention from the prime object of treatment, the rapid and systematic cor- 
rection of deformity. Of the simpler braces, that used by Judson is one 
of the best and will serve as a type to illustrate this form of treatment. 
The method of application may be described in Judson's own words. 

" The apparatus which I have conveniently used to effect this reduc- 
tion before the child learns to stand, is a simple retentive brace which 
acts as a lever making pressure On the outer side of the foot and ankle, 
at A, in Figs. 398 to 401, inclusive, and counter-pressure at two 
points, one on the inner side of the leg, at B, and the other at the 
inner border of the foot, at C. It is advisable to keep in mind that 
this simple instrument is a lever, because, if we know that we are 
using a lever with its three well-defined points of pressure, we can 
make the apparatus more efficient than if we view it, in a more general 
way, as an apparatus for giving a better shape to the foot. 
37 



578 



DEFORMITIES OF THE FOOT. 



" I use a little brace made of sheet brass, doing the work with a few 
simple tools. An advantage of doing the work one's self is that there 
is no room for doubt as to where the blame lies if the apparatus does 
not work well. Two curved disks, B and C, Figs. 400 and 401, are 
riveted to a shank, D, and thus is formed that part of the brace which 
applies the two points of counter-pressure, while, on the other hand, 
the point of pressure is brought into action by a third disk, or shield, 
A, which is drawn tightly against the outer side of the foot and ankle, 
and held in place by a strip of adhesive plaster E, which includes the 
limb and the piece which connects the two disks, B and C. The disks 
are lined with two or three thicknesses of blanket, easily renewed, 
when necessary, with a needle and thread. These braces are so cheap 



Fig. 398. Fig. 399. Fig. 400. 



— > 



Fig. 401. 




Fig. 402. Fig. 403. 



Fig. 404. 



Fig. 405. 



to 



h 





The Judson club foot splint and its application. 



and easily knocked together that it is nothing to apply new and larger 
ones using heavier material for the shank as the child grows. In 
general, three sizes will be enough, the shanks being 12 gauge, f in. 
wide; 14 gauge, J in. wide; and 16 gauge, f in. wide. The disks 
are conveniently made from 22 gauge, 1 J in. wide. The rivets are 
copper belt-rivets, No. 13. A lip turned on the edges of the disks, 
with the flat pliers, gives stiffness to the thin brass, and protects the 
skin from the rough edge. If more easily obtained, tin disks, light 
bars of iron or steel, and ordinary iron rivets, would doubtless answer. 
" The brace is applied with three strips of adhesive plaster. The 
upper and lower pieces, F and G, Fig. 401, are simply to keep the 
apparatus in place, which they do effectively if ordinary gum plaster 



TENOTOMY. 579 

is used, while, by drawing the middle strip, E, tightly over the shield, 
and straighteniug the brace from time to time, the deformity is grad- 
ually and gently reduced. At each re-application the brace is made a 
little straighter than the foot at that stage. This may readily be done 
by the hands, and then the adhesive strip is to be tightened over the 
shield, till the shape of the foot agrees with that of the brace. After 
a few days, the brace is to be made still straighter, and again re-applied, 
and made tight till another point of improvement is gained. The 
brace is applied very crooked at the beginning of treatment, as in Figs. 
399 and 401, and is straightened from time to time, and a longer 
brace applied as the deformity is reduced and the patient grows. It 
should be removed every week, or two weeks, and an interval of a few 
days allowed for freedom from the brace, when the mother is advised 
to manipulate the foot constantly, using as much force as she will in 
the direction of symmetry. Manipulating the foot during these inter- 
vals is of great importance, as cases have occurred in which varus and 
equinus have been entirely overcome by the mother's hand alone." 

" By this simple and prosy treatment, carried out systematically and 
without haste, or violence, or pain, the foot, unless it is a frightful ex- 
ception, may with certainty be changed from varus to valgus. At 
the same time the tendo Achillis is lengthened till the position of the 
foot is near the normal, or at right angles with the leg, as the result of 
manipulation and giving the brace from time to time a partly antero- 
posterior action. Figs. 400 and 401 show approximately the shape 
of the brace at the beginning of treatment, Figs. 402 and 403 when 
the varus is reduced, and Figs. 404 and 405 when valgus has taken 
the place of varus. The foot, in this latter stage, may not hold itself 
valgus, when left to itself, but with almost no force and with one finger 
it may be pushed into valgus." 

When the varus deformity is reduced, the equinus is gradually cor- 
rected by carrying the splint behind the internal malleolus, and finally, 
if necessary, direct upward pressure may be applied by lengthening 
the brace and applying it to the posterior aspect of the foot and leg. 
It may be noted that manipulation and stretching the contracted parts 
when the brace is removed, is of much importance in the correction of 
deformity by this or other means. Splints of wood, tin, felt and the 
like, may be employed, but they present no particular advantage over 
that which has been described. 

Tenotomy. — The equinus has been spoken of as the secondary de- 
formity, but its complete correction is often more difficult than that of 
varus. The mechanical stretching of the contracted parts by means of 
the plaster of Paris bandage, or the brace, is often accomplished with 
ease. But in many instances time will be gained, after the foot has been 
forced into the position of equiuo-valgus, by the division of the tendo 
Achillis, which is the most resistant of the shortened tissues. After 
division of the tendon, it is often necessary to use considerable force to 
stretch the other contracted parts, and to force the foot up to the limit 
of normal dorsal flexion, which is the object of the operation. Occa- 



580 DEFORMITIES OF THE FOOT. 

sionally the obstacle seems to be in the posterior ligament of the ankle, 
and it is sometimes of service to reinsert the knife and to divide this 
structure, in part at least, so that it will give way under manipulation. 
When the foot has been forced into the position of over-correction, it 
is fixed in a plaster bandage which is allowed to remain for several 
weeks, until the interval between the separated ends of the tendon is 
filled in with the new tissue. 

In many instances, the leg is rotated inward upon the thigh, and the 
habitual attitude is accompanied by accommodative changes in the liga- 
ments of the knee joint. During the rectification of the club foot, this 
secondary distortion may be, in part at least, corrected by forcible 
manual rotation of the lower leg outward several times daily. 

Recapitulation. — The management of the first stage of the treatment 
of infantile club foot is then — manipulation of the foot by the nurse 
from birth until systematic rectification can be begun — mechanical 
correction, first of the varus and then of the equinus deformity, termi- 
nating with a period of retention in the over-corrected position (cal- 
caneo-valgus). Division of tendons, other than the tendo Achillis, is 
not often necessary. The time required for the completion of the first 
stage of treatment, or over-correction of deformity, should not, under 
favorable conditions, exceed three months. 

The rapid correction of deformity in the manner described, begun 
as early as possible and accomplished as quickly as possible, cannot be 
too strongly urged. In the first months of life the tissues are not re- 
sistant, the bones are practically entirely cartilaginous, and when the 
foot in its external appearance is rectified, the rapid growth in the 
first months of life will change the internal structure to conform to the 
normal conditions. The fear of atrophy, compression or other harm 
from the temporary fixation, necessary during rectification, is ground- 
less, and in fact, exercise so-called, except in the direction opposed to 
deformity, is harmful rather than beneficial. 

Correction of deformity may be accomplished by holding the foot in 
an improved position by strips of adhesive plaster, or by the elastic 
traction of rubber bands, attached to the leg and foot. As compared 
with the ease, rapidity, and certainty of correction by means of the 
plaster bandage, such methods are uncertain and ineffective and they 
will not therefore be described in detail. 

The Second Stage of Treatment. Support and Restoration of Function. 
When the deformed foot has been corrected, in the sense that all 
normal motions can be carried out by passive force, the first and most 
difficult part of the treatment will have been completed, and, in some 
instances, the deformity is actually cured. Such a result is unusual 
however, for although the foot may be normal in appearance, its mus- 
cular balance has not been restored. This is shown by the fact that 
when support is removed, the foot usually hangs downward and inward, 
and there is little apparent power in the dorsi-flexors and abductors to 
draw it upward and outward. If at this stage treatment were aban- 
doned, the deformity would almost invariably recur, at least in part. 



THE RETENTION BRACE. 



581 



For this reason, the foot must be supported in proper position until 
the slack of the lengthened tissues has been taken up by development 
in the normal attitude, aided by massage and stimulation of the mus- 
cles. Practically, support is always necessary until the child has be- 
gun to walk. 

The Retention Brace. — The form of retention brace will vary 
somewhat according to the indications of the individual case. The 
best and simplest support is the Taylor brace, the invention of Dr. 
C. F. Taylor, of New York. (Fig. 406.) This consists essentially 
of a light upright that extends along the inner side of the leg to the 
knee, and a thin steel foot plate of the exact size of the sole, with an 

Fig. 406. 





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'V* 






C x - 






a^. /2k 


. 


■-*•* 


^■■H 




;2'0skj 


• V^ 




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^fi^' 




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-/£* /li - 


Ssfe3fe - \ 




li 


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The Taylor club foot brace. 



upright flange on the inner side, rising to a point just above the dorsal 
surface of the foot, against which the foot is pressed closely so that 
recurrence of the varus deformity is prevented. The joint at the 
ankle is provided with a catch that prevents plantar flexion, but al- 
lows dorsi-flexion. By bending the upright and the sole plate, the 
foot may be held in slight abduction and eversion. The apparatus 
is applied with straps, as illustrated, and if necessary, its position 
is further fixed by a band of adhesive plaster, applied on the inner 
side of the leg to hold the heel firmly against the foot plate. The 
foot is thus held constantly at a right angle to the leg, or better in 
the early stage of treatment, in an attitude of dorsi-flexion and. val- 
gus. Occasionally, after complete rectification of the deformity, the 



582 



DEFORMITIES OF THE FOOT 



foot still turns in. In most instances, this is due to an inward rotation 
of the tibia on the femur at the knee joint, but in some cases, it is 



Fig. 407. 



Fig. 408. 








Taylor club foot brace showing the method of application and attachment. 

caused by a spiral twist of the tibia itself. In order to correct this 
secondary deformity, an extension of the upright of the brace is carried 



Fig. 409. 



Fig. 410. 





The Taylor club foot brace showing the adhesive plaster, by means of which the heel is held'down, 
and the method of attachment. This brace may be used to correct deformity as well as to retain the 
foot in proper position, as is illustrated by these figures. As a retention apparatus the foot plate 
should be held at a right angle to the upright by the stop joint shown in Fig. 406. 



METHODICAL MANUAL CORRECTION. 583 

beneath the leg, provided with a joint at the knee and is extended up 
the outer side of the thigh. At the hip it is attached by a free joint 
to a padded pelvic band of light steel. (Fig. 415.) The band holds 
the upright in the proper relation to the thigh, thus, by twisting the 
part below the knee, the foot can be rotated outward to the desired 
degree. In less marked cases the retention bands used for pigeon toe 
may be employed. (Fig. 377.) 

Methodical Manual Correction. — Several times during the 
day the brace should be removed in order that the foot may be thor- 
oughly massaged and forcibly turned, first toward valgus, that is, out- 
ward at the medio-tarsal joint so that the inner border is made con- 
vex, and then to the extreme limit of dorsi-flexion and abduction. If 
the leg is rotated inward, it is forcibly rotated outward on the femur. 
Even if the tibia is actually twisted on its long axis, the influence of 
the brace and forcible manipulation will usually correct the deformity. 
Active contraction of the weak muscles may be induced by tickling the 
sole of the foot or by the use of electricity ; and finally, the entire 
limb should be thoroughly massaged before the brace is reapplied. 

When the deformity shows no tendency to recur, the brace may be 
removed for a part of the day, later it is used only at night, and finally 
it may be discarded if the child walks normally. But it is best to 
continue the daily manipulation, more particularly the systematic 
stretching or over-correction of the foot, for a long time. Thus one 
may assure oneself that there is no tendency toward deformity, of 
which the first symptom is always a slight limitation of the range of 
dorsal flexion and of abduction. 

In many instances, the deformity may have been so thoroughly over- 
corrected by the plaster of Paris bandage or by the brace, and the 
after-treatment of massage and stretching may have been so efficiently 
applied by the nurse or parent, that the retention brace may be unneces- 
sary. On the other hand, the inclination toward deformity may be so 
marked that a brace may be necessary to hold the foot in slight abduc- 
tion and valgus for a year or longer. In other cases, the use of a 
light brace to hold the foot in the over-corrected position during the 
night is alone required. These are points to be decided by the cir- 
cumstances in each case. The period of observation and supervision 
is included in the final stage of the treatment. 

Third Stage of Treatment — Supervision. — During this period, the at- 
titudes of the limb and foot of the walking child must be carefully 
watched, and particularly the signs of wear on the sole of the shoe. 
If it shows greater wear on the outer side than is usual, it is an indi- 
cation that the weight does not fall directly on the center of the foot 
but to the outer side, and that there is therefore a tendency toward de- 
formity. This must be counteracted by making the sole thicker on 
the outer side or slightly wedge-shaped, so that the weight may be de- 
flected toward the inner border. 

This third period of treatment, or rather of over-sight of the func- 
tional use of the foot, must be continued indefinitely. In fact, it is 



584 DEFORMITIES OF THE FOOT. 

the quality of this final supervision that decides in most instances 
whether the ultimate outcome is to be what is called a satisfactory re- 
sult, or a perfect cure. 

The Treatment of Neglected Club Foot. 

The treatment of club foot, under what may be called the proper 
conditions, as outlined in the preceding pages, applies practically to all 
cases before the completion of the first year of life, and mechanical 
rectification may be successfully employed in cases far beyond this 
limit of age. As a rule, however, when the patient has walked for 
any length of time, the resistance of the tissues has increased to such 
an extent, that more rapid and effective treatment is indicated. The 
investigations of Wolff have shown that the internal structure of the 
bones corresponds to their external contour, and that the structure and 
contour are adaptations to functional use. This internal structure is 
not, however, permanent, but is readily transformed to conform to 
changes in form or function. If then, the external contour of the 
club foot were suddenly reversed, and if use of the foot were per- 
mitted in this new attitude, a transformation of the internal structure 
of the bones and at the same time of their shape, would begin at 
once. This would continue until both structure and shape had become 
adapted to habitual function. It is upon this natural power of trans- 
formation that one depends for the final and complete change of 
the distorted bones to the normal ; and what is true of a resistant 
structure, like bone, is equally true of the other constituents of the 
deformed foot. 

Age as Influencing Treatment. — There is then this very es- 
sential difference between the indications for treatment in infancy and 
in childhood. In the first instance, the foot has no essential function. 
In the walking child, however, the weight of the body and habitual 
use tend to confirm and to increase the deformity. If walking is al- 
lowed during the process of rectification of the foot, it must necessarily 
retard its progress. As a general principle of treatment, walking 
should not be permitted, until the weight of the body may aid rather 
than retard the correction of deformity. The great numbers of compli- 
cated and cumbersome machines that have been used in the treatment of 
club foot were designed to correct gradually the deformity in walking 
children. But however efficacious one or another of these may have 
been in the hands of its inventor, or of one skilled in its use, such forms 
of apparatus applied under ordinary conditions, simply serve to delay 
effective treatment and to fix rather than to correct the deformity. 
The most important function of the brace, aside from its use as a 
correcting appliance in early infancy, is to support the foot after de- 
formity has been corrected, and to guide it in its functional use until 
its normal strength has been regained. And although it may be ad- 
mitted that rectification of deformity, even in adolescence, by simple 
mechanical means alone is perfectly possible, yet, only in exceptional 



FORCIBLE MANUAL CORRECTION. 



585 



cases would one be justified in selecting a treatment so tedious, which 
offers practically no advantage over more rapid methods. 

The Rapid Correction of Deformity. — The principles on which opera- 
tive treatment is conducted are the same that govern mechanical treat- 
ment. Thus, the deformed foot must be over-corrected, and it must 
be held in the _averr corrected position, until the immediate tendency 
toward deformity has been overcome. It must then be supported, until 
the process of transformation of its internal structure is completed, 
and until^the balance of muscular poAver has been regained. This 
general rule of treatment is entirely opposed to the supposition that a 
surgical operation, no matter how radical, can be, in childhood at least, 
curative by itself alone. Operative procedures are undertaken simply 

Fig. 411. 




Reduction of the varus deformity. (Lorexz.) 

for the purpose of making the primary over-correction possible ; and 
that operation by which this object can be accomplished, with the least 
interference with the structure of the foot, should be selected. Such 
an operation is what may be called forcible manual correction. 

Forcible Manual Correction. — The patient having been anaesthetized, 
one first attempts to correct the sharp inward twist at the medio-tarsal 
joint. Supposing the left foot to be deformed, one grasps the heel 
with the right hand, in such a manner that the projection or muscular 
part of the palm lies on the outer aspect of the foot, against the most 
prominent part of its outer border, which is at the junction of the os 
calcis and cuboid bones. This hand serves as a fulcrum, over which 
the inverted foot may be bent. The forefoot is then grasped firmly 



586 



DEFORMITIES OF THE FOOT. 



by the left hand and one begins a series of outward twists over the 
fulcrum of the opposing palm, gently at first with alternate relaxation 
of pressure, but with gradually increasing force as the resistant tissues 
stretch under the tension. 

If greater force is required, a triangular block of wood, well padded, 
may be used as the fulcrum (Fig. 411), one hand pressing on the 
heel and the other on the forefoot, but there is a great advantage in 
using nothing but the hands, because one feels sure that no injurious 
force is likely to be exerted. Under this steady manipulation the foot 
soon loses its rigidity and its elastic recoil toward deformity — it becomes 

Fig. 412. 




Flattening the sole. * (Lorknz. 



so limp that with two fingers one can not only hold the sole straight, but 
can push it or bend it outwards. Thus the first stage of the method- 
ical correction has been accomplished. 

One then turns his attention to the supination which makes the outer 
border of the foot lower than the inner border. The leg is grasped 
firmly near the ankle with the left hand and with the right the foot is 
forcibly twisted in a direction downward, outward and upward, over 
and over again, with steadily increasing force as the tissues slowly yield, 
until it may be forced into a position of extreme abduction, so that 
the sole may be made to look outwards and downwards — the reverse of 
the former attitude. 



FORCIBLE MANUAL CORRECTION. 



587 



Fig. 413. 



One next stretches the contracted plantar fascia and reduces the cavus 
which is usually present, by forciug the forefoot toward dorsiflexion, 
against the resistance of the contracted tendo Achillis, until the sole is 
made perfectly flat. (Fig. 412.) Finally, the fourth, and often the most 
difficult part of the rectification, that of forcing the displaced astragalus 
into its proper position between the malleoli, is attempted. To ac- 
complish this, the tendo Achillis is first divided subcutaneously, and if 
necessary the posterior ligament of the ankle is also divided at the same 
time. The patient is then turned upon his face so that with the knee 
resting on the table the leg is held upright. This allows one to hook 
the fingers about the extremity of the os calcis while the hand and arm, 
lying along the sole of the 
foot, may be used as a 
lever to force it toward 
dorsal flexion as the os 
calcis is drawn down- 
ward. In this manner 
forcible stretching is con- 
tinued until the dorsum 
of the foot can be brought 
almost into apposition 
with the crest of the tibia. 
When the operation has 
been completed, the foot 
should be perfectly limp. 
It is usually somewhat 
congested from the pres- 
sure of the fingers, but 
it is warm and the circu- 
lation is unimpaired. 

One may assume that 
in the change that has 
taken place from rigid 
deformity to a limp foot 
that can be moulded into 
the desired shape, the 
component parts of the 
deformed foot must have been subjected to considerable violence ; that 
ligaments and muscles must have been stretched, and, it may be, rup- 
tured ; that new surfaces are now opposed to one another in the articu- 
lations, and that the bones have been forced into approximately normal 
position. This method of treatment has a great advantage over the 
ordinary operative treatment, in that the entire foot participates in the 
correction, instead of a limited portion, as when, for example, bone is 
removed by cuneiform osteotomy. It has a second and almost equally 
important advantage, in that the immediate use of the corrected and 
yielding foot is possible in the place of the necessary rest that must 
follow cutting operations. For these reasons forcible massage should 




Reduction of the equinus deformity. ' (Lore>*z.) 



588 



DEFORMITIES OF THE FOOT. 



Fig. 414. 



be the operation of choice, and preliminary, at least, to more severe 
procedures in the treatment of resistant club foot in childhood. The 
only disadvantage of the operation is the actual labor which it necessi- 
tates on the part of the surgeon, usually twenty minutes or more of 
rather exhausting work. 

The foot must now be fixed by a plaster bandage in an over-corrected 
position. It is first evenly covered with a layer of cotton, and a broad 
bandage of canton flannel and while it is held by the assistant, the 
plaster bandages are applied from the tips of the toes to the upper 
part of the thigh. It is important that the toes should not project 
beyond the bandage, because of the swelling that sometimes follows. 

It is important, also, that the foot 
should be held in the proper posi- 
tion while the bandage is harden- 
ing, and that it should not be manip- 
ulated to any extent after the band- 
age is applied, in order that no rigid 
wrinkle may press against the skin. 
The bandage is applied above the 
knee in order that the tibia may 
be rotated outward to its normal 
position and held there, and because 
more effective fixation may be as- 
sured and greater pressure exerted 
on the foot in walking. To utilize 
this pressure to better advantage 
the bandage should be made very 
thick beneath the sole, and a thin 
foot plate of wood should be incor- 
porated in the plaster. When the 
bandage is applied the position of 
the foot should be that of over-cor- 
rection of deformity, flexed beyond 
the right angle, twisted far outward, 
and the outer border should be elevated considerably beyond the level 
of the inner border. (Fig. 414.) 

One would suppose, after using the force that has been necessarily 
applied, that much pain and swelling would follow. This is, however, 
not the case. Often, on the following day, the patients are able to 
stand upon the foot, and always within the first week if the bandage 
has been properly applied. The pain following this operation is far 
more often caused by pressure of an ill-fitting bandage than by the 
violence that has been used. Thus one should be careful to remove 
sections of the bandage if it appears to cause undue discomfort. These 
points are usually the front of the ankle, the back of the heel and the 
inner border of the great toe. 

The Importance of Functional Use. — The immediate use of 
the foot is encouraged, in order that the weight of the body falling on 




The attitude of over-correction in 
which the feet are fixed after the opera- 
tive treatment. 



THE IMPORTANCE OF FUNCTIONAL USE. 589 

the yielding structure may still further correct the deformity. Although 
only the heel and inner border bear weight directly, yet the pressure of 
the foot plate on the parts that do not come in contact with the floor is 
usually sufficient to mould the foot into its proper shape. If greater 
pressure is thought to be necessary, wedges of wood or cork may be 
attached to the sole of the plaster bandage so that all parts may bear 
weight equally. The bandage is covered by a stocking ; a slipper may 
be worn indoors and an ordinary over-shoe for street wear. 

The first bandage should be removed at the end of about three weeks 
as it will have become loose. The foot will then be found to be ex- 
tremely flexible, and by an enthusiast it might be considered cured. But 
knowledge of its previous condition should make it evident that a much 
longer time will be necessary to allow for its consolidation in the new 
position. At this time almost no evidence of the operation remains, ex- 
cept, it may be, slight discoloration of the skin. The foot is again held 
as far as possible in the over-corrected position and another plaster 
bandage is applied, usually as far as the knee only. This remains for 
four weeks, or longer if it is still unbroken. The patient uses the 
foot constantly, and is drilled in the proper method of walking, so that 
the muscles of the leg may become accustomed to the new and normal 
attitudes. 

At the end of another month or more, the plaster is replaced by a 
brace to be worn inside the shoe, usually of the simplest description, 
consisting of an upright bar with a calf-band, attached to a steel sole- 
plate by a joint that will allow dorsal flexion but checks extension at 
a right angle. This is applied because the dorsal flexors, after years 
of disuse, only slowly recover sufficient power to resist the action of 
the opposing group and the force of gravity. 

The second stage of the treatment is now begun. This may be di- 
vided into a period of active treatment and one of supervision. The 
first, or treatment stage, consists in massage of the entire leg and of 
the foot to stimulate the growth of the atrophied muscles, and method- 
ical manipulation of the foot several times a day. The important 
point in this manipulation is to force the foot with the hand to 
the extreme of the range of motions possible immediately after the 
operation, viz., eversion, abduction and dorsal flexion, in the same 
order, as at the time of operation. At the same time the patient 
attempts voluntarily to carry out these motions by his own muscles, 
the power being supplied by the hand of the masseur. Slowly the 
muscles gain in strength and ability and w T hen normal muscular power 
and balance have been regained the patient is practically cured. But 
for long afterward supervision is kept up, of the patient's attitude, of 
the manner of using the foot, of the wear of the sole of the shoe, and 
the like ; and by constant drilling and stimulation the attempt is made 
to restore the normal appearance and function. 

One cannot exaggerate the importance of this after-treatment, and of 
supervision at least, on the part of the surgeon. The active treatment 
may often be left to the parents. But constant supervision is neces- 



590 



DEFORMITIES OF THE FOOT 



Fig. 415. 



sary to keep this after-treatment, which seems so common-place and sim- 
ple, up to the proper pitch ; to assure oneself that the range of motion 
regained by the operation does not gradually become more and more 
restricted, even though the contour of the foot appears to be normal. 

Forcible manual correction may be employed with advantage from 
the second to the tenth year, although the limits may be extended in 
either direction in special cases. In this operation, as described, the 

tendo Achillis is the only structure di- 
vided. There is no particular objection 
to subcutaneous division of other ten- 
dons or ligaments in connection with 
forcible manual correction. But in such 
prolonged manipulation it is much bet- 
ter if the skin, which itself must be 
stretched, is unbroken and dry, rather 
than moist from the bleeding from punc- 
tured wounds. For this reason it is 
well to correct the deformity without 
extensive tenotomy if possible. 1 

Secondary Deformities. — In cases such 
as have been described, a certain amount 
of secondary deformity of the leg is often 
present. Knock knee rarely requires 
other treatment than daily manual cor- 
rection, in connection with the massage 
of the foot and leg. Hyper-extension 
at the knee will correct itself during the 
treatment of the foot, which being fixed 
in an attitude of dorsal flexion obliges 
the patient to bend the knee habitually 
in walking. Inward rotation of the leg 
upon the thigh is often present. This 
may be overcome by methodical ma- 
nipulation and by the use of a brace 
that is attached to a pelvic band. 
(Fig. 415.) 

In many instances, particularly in 
childhood and adolescence, the patient 
has so long walked with exaggerated 
outward rotation of the femur, that after correction of the deformity no 
inward rotation of the foot appears, even though inward rotation of the 
tibia be present. In other cases the inward rotation of the foot is 
caused by a failure to completely replace the astragalus between the 




The Taylor club foot brace with 
pelvic band, to prevent rotation of the 
leg. The brace is shown before the 
covering and straps are applied. 



1 Forcible manual correction appears to have been described first by Delore. Lorenz 
employs the method in connection with his osteoclast to the exclusion, practically, 
of all other treatment. (Heilung des Klumpfusses durch das modellirende Eedresse- 
ment, Wiener Klinik, Nov., 1895. ) The modification of the treatment that has been 
described has been employed by the author for many years. 



SUBCUTANEOUS TENOTOMY. 591 

malleoli. Occasionally the tibia is actually twisted on its long axis, so 
that an osteotomy may be required in order to overcome the deformity. 

Malleotomy. — In confirmed club foot, of the type under considera- 
tion, the chief obstacle to perfect correction is often the astragalus. This 
is displaced forward, downward and inward, only the posterior portion 
of its articulating surface being contained between the malleoli. Thus 
the space between the two bones may have become insufficient for the 
anterior and wider part of the body of the astragalus. In such cases, 
even after division of the tendo Achillis and the posterior ligament of 
the ankle, dorsal flexion still remains restricted and examination shows 
that the astragalus still projects as before, even though the foot has 
been forced into a position of apparent dorsi-flexion and abduction. 
This apparent correction is the result of over-correction at the medio- 
tarsal joint, of outward rotation of the tibia upon the femur and of 
backward displacement of the fibula. 

In such instances the malleoli may be separated from one another 
by dividing the ligaments that hold them in apposition. A straight 
incision about two inches long is made directly over the anterior as- 
pect of the articulation, the ligaments are divided and, by inserting 
a thin chisel, the bones are pried apart, while the astragalus is replaced 
in the proper position. This is usually easy if the restraining tissues 
on the posterior part of the ankle have been divided. The wound is 
then closed and the foot held in the over-corrected position by a plaster 
bandage. Complete correction of the varus deformity should, of 
course, precede this operation. 

It might seem on first consideration that if immediate correction 
of deformity could be so easily accomplished in the confirmed cases, 
it should be employed even in infancy. There are, however, practical 
reasons against it ; first, because the foot is so small that it cannot be 
easily manipulated, second, because even after it is corrected it must 
be supported until the child begins to walk, and third, because the foot 
can be so easily straightened without an operation, which, even of so 
slight a character, is sometimes cause of much anxiety to the parents. 
For these reasons although immediate reduction of deformity is a 
thoroughly practical and safe operation, it is rarely performed until a 
later time. 

Subcutaneous Tenotomy. 

The division of tendons and other tissues by the subcutaneous 
method, has been mentioned incidentally but as it has so long occu- 
pied an important, and even at one time the most important, place in 
the treatment of club foot, the operation and its effects may be described 
somewhat in detail. 

Tenotomy, as has been stated, is performed for the purpose of re- 
moving an obstacle to the correction and over-correction of deformity. 
In the acquired or paralytic form of club foot, one or more shortened 
tendons may be the chief obstacles to reposition. But in the congenital 
form, in which all the tissues have grown into deformity, the shortened 



592 DEFORMITIES OF THE FOOT. 

tendons are oy no means the only resistant parts, and tenotomy should 
be considered therefore, merely as an incident in correction. In the 
ordinary treatment of infantile club foot, tenotomy may often be dis- 
pensed with, and in the great majority of cases division of the tendo 
Achillis is alone required. 

When the tendon has been divided, the deformity is immediately 
over-corrected ; thus the two extremities are separated to the extent 
necessary to allow the improved position. At the end of three weeks 
or more, or at the time when the first plaster bandage is removed, the 
space will be filled with new material, and in another month the splice, 
which will be somewhat larger and thicker than the normal, should be 
strong enough for use. The slight thickening at the site of the opera- 
tion may be felt for a year or more, but for all intents and purposes, 
the new and lengthened tendon is perfectly normal, as is the function 
of the muscle of which it is a part. 

The process of repair is somewhat as follows : Immediately after 
the operation the space between the divided ends of the tendon is filled 
or partially filled with blood ; then leucocytes appear, which with 
those in the blood clot serve as pabulum for the plasma cells which 
migrate from between the fasciculi of the tendon and from the tendon 
sheath. The fibrin and red corpuscles of the clot are absorbed, the 
extremities of the divided tendon soften and become fused with the 
new material, which begins to take on the form and consistency of true 
tendon, and to separate itself from the adherent sheath. This new 
tendon, according to Tubby, differs from the normal structure in that 
the fibrous fasciculi are more irregular and its substance is more like 
scar tissue, but practically it is perfectly normal in its appearance and 
function. 

Since the tendon sheath serves an important purpose in repair, it 
should be disturbed as little as possible. For this as well as for other 
obvious reasons, subcutaneous tenotomy of the tendo Achillis, which 
is so prominent and so distinct from other important parts is to be pre- 
ferred ; but if more extensive division of other tendons is required, the 
open operation is often indicated. 

Division of the Tendo Achillis. — For this operation ansesthe- 
sis is usually required, preferably by means of nitrous oxid gas, and 
it is hardly necessary to state that surgical cleanliness, even in so 
slight a procedure, is essential. 

The instrument should be small and very sharp so that no force is 
required in the operation ; the blade should be as long as the tendon 
is wide. The patient is turned upon the side or to the prone position, 
so that the foot may be held with the heel upward by the left hand. 
The position and size of the tendon is ascertained by careful palpation, 
and the knife is then inserted to its inner side, at about the level of 
the extremity of the internal malleolus. The flat surface of the blade 
is held parallel to the tendon, and it is passed beneath it until its 
point can be felt beneath the skin on the opposite side. The edge is 
then turned upward and the tendon, being made tense, is divided by a 



THE CORRECTION OF CONFIRMED CLUB FOOT. 593 

sawing motion of the knife. When the division is complete, as indi- 
cated by the separation of the divided ends, the knife is withdrawn, 
and the minute opening in the skin, from which there is usually slight 
bleeding, is covered with a pledget of aseptic cotton. The foot is 
forced into dorsal flexion and is securely fixed by a plaster bandage. 
In applying the dressing one should take care that no pressure is 
brought upon the seat of operation, as this might interfere with the 
effusion of plastic material. As soon as the discomfort attending the 
operation has subsided the patient is encouraged to stand and to walk. 
Functional use, far from retarding repair, is, by stimulating the cir- 
culation, an important agent in assuring firm and rapid union. 

Division of the plantar fascia is not infrequently necessary and 
should be performed subcutaneously. The tenotome is inserted be- 
neath the skin at about the center of the concavity to one or the other 
side of the central band of the fascia, which is divided by a sawing 
motion of the knife. The part is put upon the stretch, and other resist- 
ing bands to the outer and inner side are divided in the same manner ; 
the cavus is then corrected by manual or instrumental force. The opera- 
tion like that upon the tendo Achillis is practically free from danger. 

Division of the tibialis axticus is not often necessary, as this 
tendon offers little resistance to the rectification of deformity of the 
ordinary type. 

The tendon of the tibialis posticus may be divided together with 
that of the tibialis anticus near the points of attachment. If the oper- 
ation is required, it may be combined with simultaneous section of the 
calcaneo-scaphoid ligament, with which are blended the anterior 
part of the deltoid and fibers of the anterior ligament of the ankle. 
(" The Astragalo-Scaphoid Capsule," Parker.) According to Parker's 
directions, the foot should be strongly abducted to make the parts tense. 
The tenotome is entered directly in front of the anterior border of the 
internal malleolus, its cutting edge being turned forward between the 
skin and the ligament. It is then turned toward the ligament, and the 
tissues are divided to the bone. The blade is then made to enter the 
interval between the astragalus and the scaphoid, and is carried down- 
ward and forward to divide the inferior part of the ligament and at the 
same time the tendons of tibialis anticus and posticus. 

The posterior ligament of the ankle joint may be divided or suffi- 
ciently weakened, so that it may be ruptured after section of the tendo 
Achillis by passing the knife directly downward in the middle line 
upon the upper border of the astragalus. 

The Correction of Confirmed Club Foot by the Method 
of Julius Wolff. 

Wolff's treatment of club foot as described by Freiberg, a former 
assistant in his clinic, may be summarized as follows : 1 The patient 
is anaesthetized, and with the hands and by the use of a moderate 

1 Med. News, Oct. 29, 1892. 
38 



594 



DEFORMITIES OF THE FOOT. 



amount of force, the deformity is reduced as far as possible. The 
foot is held in the improved position by means of strips of ad- 
hesive plaster, passing from the dorsal surface of the inner border of 
the foot under the sole and up to the outer aspect of the leg. The 
leg and foot are then covered with cotton from the tuberosity of the 
tibia to the tips of the toes and a plaster bandage is applied. As the 
plaster is hardening, the position of the foot is still further im- 
proved by pressing the heel inward and the forefoot outward and up- 
ward. Two fenestra are cut in the plaster at the points of greatest 
pressure ; one over the external surface of the ankle, and the other over 
the internal surface of the great toe. If tenotomy is considered neces- 
sary, it is usually performed as a preliminary operation several days 
before forcible correction. 

On the third or fourth day after the operation, a wedge-shaped sec- 
tion is cut from the bandage on the outer side of the ankle joint and a 
linear division is made about the ankle, so that the leg and the foot 
parts of the bandage are separated. (Fig. 416.) The leg being held 
firmly, the foot is forced outward and upward to 
Fig. 416. the extent that the wedge-shaped opening in the 

plaster will allow, and the two sections are then 
united by a covering of plaster bandage. For the 
secondary correction anaesthesia is not required. 
At intervals of several days larger wedges are re- 
moved and the manipulation is repeated until the 
patient stands with the foot in a satisfactory atti- 
tude, that is in pronation, abduction and dorsi- 
flexion. If the deformity is extreme the bandage 
may be reapplied before the correction is com- 
pleted with advantage. One should take care that 
the toes are not compressed, but lie on the same 
plane, in normal relation to one another. When 
rectification is complete the plaster bandage is 
covered with strips of pine shavings, held in place 
by a crinoline bandage, and painted with carpen- 
ter's glue. When this is hardened, the whole is 
covered with a thin silicate bandage ; over this, 
the shoe is fitted and the patient is encouraged to 
walk. This form of dressing is used until the trans- 
formation of the deformed parts may be supposed 
to be complete, the time varying with the case, from a few weeks to a 
year. The time required for the primary correction is from a week to 
a month. When the bandage is finally removed, massage and exer- 
cises are to be employed. 

Wolff's treatment has been thoroughly tested at the Hospital for 
Ruptured and Crippled. It is an efficient means of correction al- 
though somewhat tedious. It may be more conveniently employed 
in later childhood and adolescence than at an earlier age. 




The points at which the 
bandage is divided and the 
wedge removed. (Frei- 
berg.) 



THE THOMAS METHOD. 



595 



Fig. 417. 



Forcible Correction of Deformity by Means of Osteoclasts 
and Wrenches. 

In place of manual correction greater force may be employed by means 
of wrenches or osteoclasts to overcome the deformity. There is this 
important difference between the two procedures : force may be applied 
by the hands for as long a time as is necessary without fear of injury, 
while force applied by a machine must be momentary because of the 
pressure and strain on the parts where the leverage is exerted. Manual 
force continuously applied may be supposed to stretch the resistant 
parts, and although much less power is exerted it is really more effec- 
tive than the sudden and momentary force of the wrench or osteoclast. 
By manual rectification the operation may be continued until the de- 
formity has been over-corrected, while complete correction by means of 
instruments may necessitate several 
operations. 

The Thomas Method. — Of in- 
strumental correction, that by means 
of the Thomas wrench is one of the 
simplest and most efficient. The 
wrenching may or may not be pre- 
ceded by tenotomy, a point to be de- 
cided by the resistance of the parts. 
As a rule division of the tendo 
Achillis is alone necessary. The in- 
strument is a simple heavy monkey 
wrench, of which the jaws have 
been replaced by two strong pins 
slightly bulbous at the ends to keep 
the covers of rubber tubing from 
slipping off. 

The wrench is applied to the in- 
side of the foot and screw r ed 



ner 




down so that it may " bite " and 
hold its place firmly, for if it slips it 
is likely to abrade or tear the skin ; 
then with considerable force the 
foot is twisted outward and upward. 
(Fig. 417.) The " key note" of 
the operation is to so wrench the 
foot that it loses its elasticity, and 
shows no tendency to recoil toward 
deformity. The foot is then placed 
in the best possible position and is retained there by the Thomas 
foot splint or by a plaster bandage. In certain instances one may 
complete the rectification at one operation, but this not usually at- 
tempted, the procedure being repeated at intervals of a few days until 
the deformity has been over-corrected. In very resistant cases, eight 



The Thomas wrench as used in the correction 
of club foot. 



596 



DEFORMITIES OF THE FOOT. 



or ten applications of force may be necessary. When the deformity 
has been rectified, the foot is held in the over-corrected position for 
several weeks by the splint or by the plaster bandage. 

As a walking appliance a simple upright of iron with a calf band is 
applied to the inner side of the leg, from a point just below the knee to 
the heel of the shoe into which it is inserted, as is the Thomas knock 
knee brace. (Fig. 293.) By bending the upright the foot may be 
kept in slight valgus, and this position is still further assured by mak- 
ing the outer side of the sole of the shoe thicker than the inner so that 
the weight falls upon the inner border of the foot. In many instances, 

the walking brace may be 
Fig. 418. dispensed with in the after- 

treatment, but a light brace 
is usually worn to hold the 
foot in the corrected position 
during the night, until the 
power of the abductors and 
dorsal flexors has been re- 
gained. Massage and ma- 
nipulation are used in the 
after-treatment in the man- 
ner already described. 

Properly applied the treat- 
ment is satisfactory and free 
from danger. Sloughing of 
the tissues caused by the 
pressure of the instrument 
or by the plaster bandages 
has been reported, but such 
accidents have not occurred 
in the extensive practice of 
Thomas and Jones. 

Correction by Means of 
the Osteoclast. — The late 
Mr. Grattan, of Cork, used 
the osteoclast that goes by 
his name (Fig. 296) to crush 
and to over-correct resistant 
club foot. The operation may include beside the correction of the de- 
formity of the foot itself, fracture of the leg above the malleolus, to 
turn the foot toward valgus, and a second fracture half-way up the 
limb, to overcome the inward rotation or twist of the tibia. Mr. Grat- 
tan's results have been very satisfactory. Other appliances constructed 
on somewhat similar principles may be employed. Of these, the Lor- 
euz osteoclast 1 and the Bradford 2 lever apparatus are the most effective. 
The Open Incision Combined with Forcible Rectification of De- 
formity. Phelps' Operation. — When extensive division of contracted 

1 Wiener Klinik, Nov.-Dec, 1895. 2 Bradford and Lovett, 2d ed., p. 414. 




Resistant club foot in later childhood. 
(See Fig. 419.) 



PHELPS' OPERATION. 



597 



parts is indicated, the open incision is to be preferred because of the 
opportunity thus oifered for the recognition, and for intelligent selec- 
tion, of structures that require division in the final correction of the 
deformity. 

Phelps' operation is essentially simply the division of resistant parts 
through an incision on the inner border of the foot, combined with 
sufficient force, manual or instrumental, to over-correct the deformity. 
It is the most conservative of the more radical procedures, and by it 
even the most severe type of deformity in the adult can be corrected ; 
that is to say, the deformity may be overcome and a serviceable foot 
may be assured to the patient. Perfect functional cure is not possible 
when deformity has become habitual after many years of neglect. 

The steps of the Phelps operation are as follows : After proper sur- 
gical preparation the Esmarch bandage is applied. The tendo Achillis, 
and usually the posterior liga- 



Fig. 419. 



ment of the ankle, are divided 
subcutaneously, and by manual 
or instrumental force one at- 
tempts to correct the plantar flex- 
ion. An incision is then made 
on the inner border of the foot, 
just below and in front of the 
internal malleolus, which is ex- 
tended directly downward over 
the head of the astragalus to in- 
clude the inner quarter of the 
sole. Through the incision all 
resistant parts are divided in 
order, as stated by Phelps. 

1. The tibialis posticus, and 
the anticus, if it offers resistance. 

2. The abductor pollicis. 

3. The plantar fascia. 

4. The flexor brevis digitorum. 

5. The long flexor of the toes. 

6. The deltoid ligament in all 
its branches. 

During the successive division 
of the tissues, repeated attempts 
are made to correct the foot, and 
only those structures are divided 

that present themselves as tense and resistant tissues when the foot is 
forcibly abducted. 

In the adult type of club foot no particular effort is made to recog- 
nize the different structures, but all the tissues on the inner side of the 
foot including blood vessels and nerves, the deep ligaments, and oc- 
casionally the tendon of the peroneus longus muscle, are divided. 
Even then it is necessary to apply considerable force to correct the de- 




The deformity (Fig. 418) corrected by Phelps' 
operation and by cuneiform osteotomy of the os 
calcis. 



598 



DEFORMITIES OF THE FOOT. 



formity. Id certain instances the rectification of deformity necessitates 
osteotomy of the neck of the astragalus, or the removal of a cuneiform 
section from the os calcis. The object of the Phelps operation is, by 
the use of force and by division of resistant tissues, to over-correct the 
deformed foot at one sitting, and as much force and as extensive di- 
vision of tissues as are required, should be employed by the operator. 
When the foot can be held in the desired position without resist- 
ance, the wound is covered with Lister protective, the foot and leg 
are thickly covered with gauze and cotton, a plaster bandage is applied 

and the limb is elevated. The 
Fig. 420. large gaping wound closes by 

granulation in from one to 
three months. 

By this operation the foot, 
even in severe cases in adult 
life, may be made straight in 
appearance. It is evident, 
however, that in such cases 
the correction of the defor- 
mity of the bones is by no 
means always perfect, for the 
forefoot may be simply twist- 
ed outward and upward while 
the astragalus and os calcis 
may remain in an approxi- 
mation to their original de- 
formity. After thorough 
over-correction by the Phelps 
operation the danger of re- 
currence of deformity in the 
adult and adolescent type of 
club foot is not great, and 
in many instances support 
other than that of the plaster 
bandage for several months 
after the operation may be 
unnecessary ; but in childhood the ordinary precautions in after-treat- 
ment to prevent relapse will be necessary. 

Malleotomy may be employed with advantage in connection with 
this operation. (See page 590.) 

Operations on the Bones. 

Osteotomy of the neck of the astragalus, as a supplementary part of 
the operation of forcible correction, has been mentioned. In certain 
instances, particularly in the adolescent or adult type of deformity, the 
displaced astragalus may offer such an obstacle to correction that its 
removal is indicated — an operation first performed by Mr. Lund, of 
Manchester. 




Kesistant club foot in later childhood. 
(See Fig. 421.) 



CUNEIFORM OSTEOTOMY. 



599 



Astragalectomy. — The astragalus is usually removed by means of 
an incision passing over its most prominent part, in a direction for- 
ward and downward from the tip of the external malleolus, between 
the tendons of the peroneus brevis and tertius. The soft parts are 
drawn aside, the ankle and astragalo-scaphoid joint are opened and the 
attachments to the scaphoid, and, as far as possible, those at the inner 
and outer border, are divided. The foot is then adducted so that the 
head of the bone may be seized with forceps and drawn upward, the 
interosseous ligament and the internal lateral ligament may be divided 
with curved scissors and the bone may be removed. If after removal 
of the astragalus the deformity can not be corrected, the anterior part 



Fig. 422. 



Fig. 421. 





After forcible correction and astragalec- 
tomy. (See Fig. 420.) 



Partially corrected club foot showing secon- 
dary knock knee. 



of the os calcis or the external malleolus should be removed as well. 
A useful movable foot may be obtained by this operation, but it by no 
means assures the patient from recurrence of deformity. It is never 
indicated as a primary operation. The varus should be thoroughly cor- 
rected as a preliminary procedure ; then the resistance that the astrag- 
alus offers to dorsal flexion, can be estimated. (Fig. 421.) 

Cuneiform Osteotomy. — The removal of cuneiform sections of bone 
from the outer border of the foot is sometimes necessary, but the 
operation should be secondary to other methods of correction. The 
aim should be to lengthen contracted and shortened tissues on the 
inner border of the foot, to the extent required for reposition ; not 



600 DEFORMITIES OF THE FOOT. 

to remove bone to accommodate these shortened tissues. If this has 
been shown to be impossible by ordinary means, then removal of 
bone may be indicated, but this is not often necessary in childhood or 
even in adolescence. If sufficient bone is removed from the adult 
foot to allow of perfect correction of the deformity, relapse is not 
usual ; but in childhood, as has been stated, no operation will take the 
place of after-treatment. 

The treatment by cuneiform osteotomy as it is ordinarily carried out 
is sufficiently simple. In severe cases, the astragalus is usually re- 
moved and a wedge-shaped section of bone is taken from the os calcis, 
cuboid, and if necessary it may include the scaphoid bone also. The 
external malleolus may be removed, if it interferes with reposition. 
Preliminary fasciotomies and tenotomies are usually performed, but 
those who favor this method of treatment rarely use force in reposition. 
In less advanced deformity the astragalus is not removed but a part of 
its body and neck is included in the cuneiform resection. The foot is 
retained in proper position until the wounds are closed ; then plaster 
bandages are employed for several months. Braces are seldom used 
in the after-treatment. 

Secondary Osteotomy. — In certain cases of relapsed or ineffect- 
ively treated club foot, even in childhood, deformity of the os calcis 
either interferes with correction of the foot or favors relapse. In such 
instances the removal of a cuneiform section of bone from the anterior 
extremity, as a supplementary part of over-correction, may be of service. 

Simple Mechanical Rectification of Deformity in Walking 
Children and in Later Years. 

It has been stated that simple mechanical rectification of deformity 
was possible even up to adolescence, but that the time required for 
such treatment, usually extending over several years, as a rule ex- 
cluded it from consideration. 

The simplest mechanical treatment is that by which the foot is 
slowly forced from equino-varus into equino-valgus by a brace on the 
lever principle, which is at first shaped to the deformity, and is then 
gradually straightened as the resistance diminishes. When the mid- 
point has been passed between varus and valgus the weight of the 
body aids in the correction of the remaining varus and equinus. The 
modification of the Taylor brace used by Judson, an advocate of pure 
mechanics in the treatment of club foot, will serve to illustrate the 
type of apparatus which, with slight change, may be employed to 
correct or to support the weakened or deformed foot. 

The brace consists of an upright, a flat tapering bar of mild steel, a 
foot-plate of steel from 18 to 16 gauge, and a strong calf band. The 
shape of the brace, the method of its attachment to the leg by straps 
of webbing and its effect in gradually changing the attitude of the 
foot from varus to valgus are shown in the accompanying figures. 

The upright is firmly riveted to the foot-plate in the angle of de- 
formity, so that the patient must walk upon his toes ; as the equinus 



SIMPLE MECHANICAL RECTIFICATION OF DEFORMITY. 601 
Fig. 423. Fig. 424. 



Q 





The Judson brace. Fig. 423 shows the construction of the brace ; the foot plate with the internal 
flange or "riser," the upright riveted firmly to it, and the calf band. Fig. 424 shows the brace ad- 
justed to fit the deformed foot. 



Fig. 425. 



Fig. 426. 



Fig. 427. 






Showing the progressive reduction of deformity. Fig. 425 shows the ordinary attitude of the neg- 
lected club foot in childhood with the adjustment of the brace, it being bent to accommodate the 
deformity. Fig. 426 shows additional details — an upright spur useful in holding the heel, and for the 
attachment of straps ; the spur of sheet brass that maybe bent over the great toe to hold it in position. 
Fig. 427 shows other details in the method of attachment, a strip of adhesive plaster with two tails in 
the place of the band of webbing. This aids in fixing the heel. (See Figs. 428, 429.) 



602 



DEFORMITIES OF THE FOOT. 



is decreased by the influence of the weight of the body, this angle is 
lessened. (Fig. 423.) 

The important points are, that the brace should be strong enough to 
hold its place under the strain of use, and that the foot shall be firmly 
secured to it, whether one or many straps of webbing are required, as 
may be seen in the figures. The use of massage and manipulation is 
of course combined with the mechanical treatment. 

By persistent attention to the details of treatment satisfactory results 
can be obtained by this method in the less resistant cases, even in 
adolescence. 

Recapitulation of the Principles of Treatment of Congenital 
Talipes Equino-Varus. 

The object of treatment is to overcome and to over-correct the de- 
formity, at as early a period of life as is possible, and as quickly as 
possible. The object of over-correction is to overcome all the resist- 
ance of the tissues that may 
Fig. 428. Fig. 429. even in the slightest degree 

limit the normal range of mo- 
tion in any direction. The 
foot must be supported in the 
over-corrected position until 
the recoil of the tissues toward 
deformity is no longer present. 
It must be supported in 
the proper relation to the leg, 
and at a right angle with it, 
until the muscular balance 
has been reestablished by 
stimulation of the weaker, 
and by limitation of the ac- 
tivity of the stronger, muscles, 
and until transformation of 
the internal structure has been 
completed. 

If efficient mechanical 
treatment is applied at the 
proper time, that is to say, in 
earliest infancy, no operation, 
other than division of the 
tendo Achillis, will be re- 
quired. 

If the deformity is not cor- 
rected or is but partially cor- 
rected, when the child has begun to walk, some form of operation is as 
a rule indicated ; but division of the resistant tissues must always be 
combined with the employment of sufficient force to accomplish the de- 
sired result, viz., over-correction of the deformity. Forcible manual cor- 




Showing the progressive reduction of deformity, 
and illustrating the process of changing the shape of 
the brace from time to time until it holds the foot in 

valgus. (See Fig. 425.) 



CONGENITAL TALIPES VARUS. 603 

rection, applied in the manner described, is the most efficient means of 
attaining this object. No instrument can equal the hand, and the force 
that can be applied by the hand is sufficient in all the ordinary cases 
in early childhood, and in combination with subcutaneous division of 
the more resistant tendons and ligaments, even in later childhood and 
adolescence. 

Forcible correction by the Thomas wrench under the same condi- 
tions, is an efficient treatment, but there is a manifest disadvantage in 
submitting a patient to a succession of operations, even of so slight a 
character, if immediate over-correction can be attained by other means. 

The Phelps operation, which combines thorough division of the re- 
sistant parts with the application of proper force to over-correct the 
foot, is the operation of selection for the more resistant cases in ado- 
lescence, in adult life, and in extremely resistant cases in childhood. 

Astragalectomy and cuneiform osteotomy are never indicated as pri- 
mary operations, but one or the other may be necessary for the com- 
plete rectification of the deformity when other means have failed. 

Complete cure of deformity, even in the later years of childhood, is 
possible by means of braces alone, but such treatment is very tedious. 
It requires not only the continuous supervision of the skilled surgeon, 
but the intelligent and persistent cooperation of the parents. The re- 
sults are in no way superior to those attained by more rapid methods, 
while the disadvantages of long-continued use of braces are sufficiently 
obvious. To the popular faith in braces as a cure-all of deformity, and 
to the unintelligent use of braces, may be ascribed now, as in former 
times, the failure of treatment of this eminently curable deformity. 
This statement seems justified, even when balanced by the equally 
fallacious belief, so prevalent among physicians, that a radical opera- 
tion, if it does not absolutely assure a cure, is, at least, the essential 
part of the treatment. 

Rectification of deformity, by whatever means, simply completes the 
first stage of treatment. Perfect cure can only be assured by 'attention 
to the small details of after-treatment, by checking the slightest im- 
pulse toward deformity, and by guiding the unbalanced foot toward 
perfect functional use. 

Other Varieties of Congenital Talipes. 

Forms of congenital distortion of the foot other than equino-varus 
are not uncommon, but as a rule these deformities are so slight, and, as 
compared to equino-varus, so easily remedied that they are relatively 
of little importance. This distinction does not apply however to ac- 
quired talipes which will be considered in the succeeding chapter. 

Congenital Talipes Varus. 

Eighty-five cases of simple varus are recorded in the table of statis- 
tics in a total of sixteen hundred and sixty congenital deformities of 
the foot. 



604 DEFORMITIES OF THE FOOT. 

This deformity often appears to be an incomplete form of equino- 
varus, but in some instances there is simply a slight inward twist of 
the foot without supination (Fig. 376) ; in fact, the forefoot seems to 
be drawn inward by the active movement of the great toe, which, in 
such cases, seems almost prehensile. (See pigeon toe.) In the more 
marked form the foot is adducted and supinated, and the tissues are 
very resistant. 

The slight grades of deformity may be treated by simple manipula- 
tion, and if deformity remains after the first year, the shoe will, as a 
rule, correct it. The more marked varieties must be treated like the 
varus deformity of ordinary club foot, by braces or by plaster, until the 
varus has been transformed into valgus. The after-treatment is the 
same as that for ordinary club foot. 

Congenital Talipes Equinus. 

This is a rare congenital deformity, about half as common, accord- 
ing to the statistics, as varus (40 cases in 1,660). The term equinus 
implies that dorsal flexion is limited, but that the foot is not deviated 
to one or the other side (toward valgus or varus). In congenital 
equinus the deformity is, as a rule, slight, and in many instances it 
may be overcome by gentle manual force applied frequently. In the 
more resistant type, mechanical correction, or tenotomy, followed by 
over-correction and support, may be necessary. 

Congenital Talipes Calcaneus. 

Congenital calcaneus is comparatively rare (28 cases in 1,660). As a 
rule the heel is prominent, the foot is habitually dorsi-flexed, and the 
dorsum can be easily brought into contact with the crest of the tibia. 
(Fig. 386.) The exaggerated cavus, that is usually present in acquired 
calcaneus, is absent. Occasionally the deformity is accompanied by 
hyper-extension of the knee, and if, as in many instances, there is a his- 
tory of breech presentation, it may be inferred that the attitude before 
birth was one of extreme flexion of the thighs upon the abdomen, the 
anterior surfaces of the extended legs being pressed closely to the ven- 
tral surface of the body, the feet being fixed in an attitude of dorsi-flexion. 
As a rule the deformity is slight, and the resistance of the tissues on the 
anterior aspect of the leg can be easily overcome by massage and man- 
ipulation. The foot should be gently forced toward plantar flexion 
several times in the day, and the weak muscles of the calf should be 
stimulated by massage. 

Cure may be hastened by the use of some simple form of retention 
splint to hold the foot in plantar flexion until the posterior group of 
muscles has recovered its power. Tenotomy or other operative treat- 
ment is rarely required. In rare instances, the tibia may be bent 
slightly backward, thus increasing the deformity. In such cases 
the distortion of the bone may be overcome by manipulation and by 
apparatus. 



CONGENITAL TALIPES VALGUS. 



605 



Congenital Talipes Valgus. 

Congenital valgus (Fig. 387) is somewhat more common than the 
preceding varieties (123 in 1,660). Not infrequently it is combined 
with a slight degree of calcaneus or equinus. The resistance of the 
contracted tissues is not great and the deformity may be overcome, in 
most cases, by persistent manipulation. If the muscular power is suffi- 
ciently unbalanced to warrant it, the foot should be held in the over- 
corrected position (varus) for some time. 

Congenital valgus is one form of what is known as weak ankle, and it 
frequently passes unnoticed until the child begins to walk. If at that 
time, in spite of massage, the muscles appear w T eak or the foot inclines 
outward when weight is borne, it is well to make the sole of the shoe 

Fig. 430. 




Congenital calcaneo-vaJgus. 

wedge shaped, the thicker part (one-quarter of an inch) on the inner 
side. In more persistent cases, a brace may be necessary, as described 
in the treatment of the acquired variety. (See the weak foot.) 

Talipes equino-valgus is less common (28 in 1,660). This must 
be treated as the other varieties, by complete over-correction of de- 
formity, manual or otherwise, and by subsequent massage and support 
if necessary. 

Calcaneo-valgus (15 in 1,660), calcaneo-varus (7 in 1,660), equino- 
cavus (1 in 1,660), valgo-cavus (1 in 1,660), cavus (5 in 1,660), are 
extremely rare as indicated by the statistics. If treated early, by per- 
sistent massage supplemented by retention apparatus, these, as well as 
nearly all slighter grades of congenital deformity, may be corrected 
and cured even, before the child begins to walk. 



606 



DEFORMITIES OF THE FOOT. 



Congenital Deformities of the Foot Associated with Defective 

Development. 

Talipes Equino-Valgus Associated with Congenital Absence of Fibula. 
This is a rare deformity, but the most common of this class. The 
foot at birth is usually in an attitude of well-marked and resistant 
equino-valgus. The leg is somewhat shorter than its fellow and the 
tibia is often bent sharply forward, sometimes to an acute angle, at a 
point somewhat below the center, as if it had been broken in utero. 
At the most prominent point the skin may be adherent or it may present 

Fig. 431. 




Congenital equino-varus with deformity of the great toes. 

a dimpled appearance. In some instances the formation of the foot is 
perfect, but more often one or more of the outer toes, with the corre- 
sponding metatarsal bones, are absent. 

Statistics. — Haudek collected from the literature 97 cases ; of these 
46 were in males, 21 were in females and in 30 the sex was not re- 
corded. In 67 (69 per cent.) there was total absence of the fibula. 
In 30 the defect was partial ; of the lower extremity of the fibula in 
17, of the upper extremity in 9, and of the middle in 2 cases. In 27 
cases both fibulse were absent or defective ; in 68 one only, the right 
in 31, the left in 25, and in the others the side was not recorded. In 
61 cases toes were lacking, and in these cases it may be inferred that 
the corresponding metatarsal bones were absent also. The fourth and 
fifth toes were absent in 27 cases, the little toe alone was missing in 15. 



TREATMENT. 607 

In many instances, as is usual in cases of defective development, de- 
formity of other parts was present; for example in 17 instances the 
patella was absent or undeveloped, and in 11 the upper extremities 
were defective. 1 

Etiology. — The cause of deformity associated with absence of bone, 
may be either an original defect in the germ or it may be due to inter- 
ference with its development. In some instances amniotic adhesions 
may be one of the predisposing causes ; the sharp bend in the tibia, 
so often present, may be due to the lessened resistance of the defective 
part. 

Treatment. — The indications for treatment are to correct the de- 
formity of the foot in the usual manner. The bend in the tibia may 
be straightened by manipulation and splinting, or by osteotomy, if 
necessary. When the patient begins to walk the foot must be sup- 
ported. A light steel upright on the outer side of the leg, provided 
with a T strap to hold the leg against it, will supply the place of the 
missing fibula. The growth of the tibia is retarded, and a final short- 
ening of three or more inches may be expected, but with care a useful 
limb may be assured. 

Talipes Varus or Equino-varus Associated with Congenital Absence of 
the Tibia. — Defective formation of the tibia is much less common than 
that of the fibula. Joachimsthal 2 records 31 cases. Of the 25 cases in 
which the sex was recorded, 17 were males and 8 females. In 23 in- 
stances the defect was of one side ; in 8 both tibiae were defective. In 
most cases the femur is somewhat shortened and its lower extremity is 
imperfectly developed. In a third of the cases the patella was absent, 
and in many instances other malformations were present. In nearly all 
the cases there was flexion contraction at the knee and the fibula was 
dislocated backward. The foot is practically always in an attitude of 
varus. The toes may be normal, but in a number of instances, the 
great toe was lacking. In possibly a third of the cases a portion of 
the tibia, usually the upper extremity, was present. 

The prognosis, as regards a useful limb is extremely bad. The 
growth of both the thigh and the leg is much retarded, and it is almost 
impossible to balance the foot upon the fibula by any form of brace. 

The ordinary treatment, after the correction of the deformity of the 
foot, has been to resect the extremities of the femur and the fibula to 
induce anchylosis. No final results have been reported but it may be 
assumed that an artificial limb would provide a more useful support 
than the short and distorted extremity. 

Congenital Deficiency and Hypertrophy. — The leg bones may be per- 
fectly formed, but one or more bones of the foot itself may be absent. 
In these cases, after the reduction of the deformity, a support to hold 
the defective foot in its proper relation to the leg must be used. 

1 Vide also Schworer, Zeits. fur Orth. Chir., Vol. III., p. 220. Kempke, Zeits. fur 
Orth. Chir., Vol. III., p. 93. Cotten & Chute, Boston Med. and Surg. Jour., Nos. 
8 and 9, 1898 (128 cases). Mazzitelli, Arch. Ortopedia, 1898, F. 5. Boinet, Eevue 
d'Orthopedie, Nov., 1899. 

2 Zeits. fur Orth. Chir., Vol. III., p. 140. 



608 DEFORMITIES OF THE FOOT. 

The foot may be divided into two parts, so that it resembles a lobster 
claw. Supernumerary toes, or deficiency of toes, or hypertrophy of 
one or more of the toes, with or without corresponding over-growth of 
the foot or leg, are not extremely uncommon. 

These deformities must be treated on ordinary surgical principles. 

Constricting Bands. 

Tightly constricting bands of scar-like tissue, which cause deep in- 
dentations in the flesh of the foot or leg, are sometimes seen. These 
are supposed to be caused by amniotic adhesions. " Spontaneous am- 
putations " of toes, or of the foot itself, are due to the same cause. 
(Fig. 390.) 

In ordinary cases, the bands require no treatment, but if they inter- 
fere with the nutrition of the foot, they may be removed. 

Congenital (Edema of the Feet. 

In rare instances, sometimes in combination with deformity, the 
tissues of the feet appear to be oedematous, although the circulation 
seems to be perfect. The condition is apparently due to obstruction 
of the lymphatic circulation. 

It should be treated by massage and by compression. 

Spina Bifida and Talipes. 

Talipes, coexisting with spina bifida, should be treated as are other 
forms of club foot. If paralysis of the lower extremities be present, 
as is often the case, the corrected feet must be supported as in the or- 
dinary forms of paralytic deformity. 1 

1 Uber missbildungen der Menschilichen Gliedmassen und ihre entstehungsweise, 
Klausner, 1900. 



CHAPTER XXIII. 
DEFORMITIES OF THE FOOT.^ Continued. 

Acquired Talipes. 

In the account of the congenital deformities of the foot it was stated 
that the form known as equino-varus was by far the most common, 
and that as compared with it, the other deformities were of slight im- 
portance. 

In the acquired varieties of talipes, the equino-varus deformity is 
much less common, the proportion being, in the congenital form, 77 
per cent, and in the acquired 32.5 per cent, of the total number. Ac- 
quired equinus comes next in frequency, 26 per cent., as compared 
with 2.4 per cent, of the congenital deformity, and every variety and 
combination of deformity finds its representative in acquired talipes, as 
may be seen in the tables. (See page 568.) 

The Etiology of Acquired Talipes. — The cause of acquired talipes is 
almost always paralysis. In the table of statistics, it will be seen, 
that in 82.8 per cent, the paralysis was of spinal origin (anterior 
poliomyelitis). In 11.3 per cent, it was cerebral, the talipes being a 
part of the deformity of hemiplegia or paraplegia. A few cases were 
caused by local disease or injury of the nerves, and the remainder, or 
5.4 per cent, were of traumatic origin. 

The distinction between the two forms of talipes, congenital and ac- 
quired, has already been emphasized. In the congenital form the de- 
formity is the essential disability, for when deformity has been over- 
come the most difficult part of the treatment has been accomplished 
and perfect cure may be expected. In the acquired form, the removal 
of deformity is but a part of the treatment, and perfect cure is not to 
be expected, except in that small proportion of cases in which the 
primary disease of the spinal cord has caused no permanent injury to 
its structure, or in which the deformity was the result of some slight 
or passing disability or disease. Again, congenital deformity cannot 
be anticipated or prevented. Acquired talipes is an effect of paralysis 
only when protective treatment has been neglected. It is a result there- 
fore that may be foreseen and thus, by proper treatment, prevented. 

Development of Deformity. — The characteristics of anterior 
poliomyelitis are described elsewhere. (Chapter XVII.) In its effect 
upon the foot the usual sequence is somewhat as follows : Immediately 
after its onset the paralysis is usually widespread, affecting the entire 
leg for example ; then follows a period of partial recovery, after which 
the amount of damage that the spinal cord has sustained may be esti- 
39 



610 DEFORMITIES OF THE FOOT. 

mated. It is during the period of partial recovery, the six months or 
more following the attack, that contractions, which lead to deformity, 
appear. If, for example, the anterior group of leg muscles is paralyzed, 
the foot habitually hangs downward, a position caused by the force of 
gravity and by the contraction of the unaffected posterior group. If 
this attitude is allowed to persist, the tissues accommodate themselves 
to the new position ; the muscles which are never extended to their 
normal limit, become structurally shortened, while the paralyzed group 
becomes elongated. Even within a few weeks after the onset of the 
paralysis, the evidences of advancing deformity are plain. The con- 
tracted tissues resist passive motion in the directions opposed to the 
habitual attitude, and the child shows evidence of pain if force is used 
to increase the limited range of motion. As has been stated already, 
paralytic talipes is an unnecessary deformity. It may be prevented 
by supporting the paralyzed part in a right-angled relation to the 
limb, and by systematic passive exercise throughout the entire range 
of normal motions ; thus improper attitudes and the secondary contrac- 
tions that fix the foot in the distorted position may be avoided. 

Anterior poliomyelitis is most common during the second year of 
life, or when the child has already begun to walk. When the first 
and more general effect of the disease has passed away, the child again 
uses the disabled limb as best it may, thus the distortion of the foot is 
increased and confirmed by the weight of the body and by functional 
use in the abnormal attitude. 

The final deformity, in a particular case, can be predicted from the 
knowledge of the function of the muscle or muscles which has been 
lost. For example, paralysis of the tibialis anticus, the most powerful 
dorsi-flexor and adductor of the anterior group, must result in equino- 
valgus. If the peroneus brevis and tertius are affected varus will fol- 
low. Paralysis of the calf muscle will cause calcaneus. Paresis or 
paralysis of the entire anterior group will cause equinus. If all the 
muscles are paralyzed, what is called a dangle foot is the result ; the 
cold atrophied member dangles from the attenuated limb with but 
little tendency to deformity unless it is capable of use, when it is usu- 
ally forced into an attitude of equino-varus or valgus. 

A slight degree of paralysis may cause so little disability that it may 
be entirely overlooked, and its later effect in causing disability or de- 
formity may not attract attention for many years. This fact has been 
mentioned in the etiology of the contracted foot. 

Differential Diagnosis Between Congenital and Acquired Deformity. — 
The history itself usually indicates the etiology, for deformity of the 
foot at birth is never overlooked by the mother. Acquired talipes is 
practically always preceded by a history of disease, or weakness, or 
injury, which was soon followed by slight, and afterward by increasing 
deformity. 

In paralytic talipes (anterior poliomyelitis), there is evidence of 
paralysis in loss of function of certain muscles, as shown by electrical 
stimulation or by pricking the foot with a pin ; later, in the atrophy 



ACQUIRED TALIPES EQUINUS. 



611 



of the muscles and often in the evident change in the nutrition and 
diminished growth of the limb. 

Only in neglected and extreme cases of talipes in the adolescent 
or adult, could there be difficulty in distinguishing between the ac- 
quired and the congenital deformity. In rare instances, it is true, 
paralysis may be present at birth, due to intra-uterine disease or to 
defect in the nervous apparatus. In such cases the cause of the par- 
alysis is usually apparent (spina bifida, or spastic paralysis associated 
with defective cerebral development) and the treatment does not differ 
from that of the acquired form. 

Acquired Talipes Equinus. 

In well-marked equinus, the foot is plantar flexed to its full limit and 
it is held in this attitude by the shortened structures on the posterior 
aspect of the leg, of which the tendo Achillis is the most important. 
The patient walks upon the heads of the metatarsal bones, the toes be- 

Fig. 432. 




Acquired talipes equinus. 



ing dorsi-flexed to accommodate the deformity. The arch of the foot is 
increased and the tissues of the sole, particularly the plantar fascia, are 
contracted. The entire foot is broadened and shortened, the breadth 
being especially increased across the metatarsal region. (Fig. 385.) 
Corresponding to the exaggerated depth of the arch, the dorsum pro- 
jects, the cuneiform bones are prominent, and the head and body of the 
displaced astragalus may be felt beneath the skin on the anterior surface 
of the foot. In rare instances, and in those cases in which all the an- 
terior muscles are paralyzed, the toes may be plantar flexed so that 
the patient walks upon their dorsal surface. 



612 DEFORMITIES OF THE FOOT 

The cavus or increased depth of the arch is due primarily to the 
falling downward of the forefoot at the medio-tarsal joint, and in 
many instances, this dropping of the forefoot is in great degree re- 
sponsible for the equinus ; in fact the os calcis is rarely plantar flexed 
to the degree commonly found in the ordinary congenital equinus. 

In the slighter degrees of the deformity when the patient still walks 
upon the sole of the foot, the toes are usually dorsi-flexed, an attitude 
due, apparently to the over-action of the extensor longus digitorum 
and proprius pollicis, as aids in dorsi-flexion. (Fig. 432.) 

The cases of slight equinus combined with cavus have been de- 
scribed already under the title of the contracted foot. (Page 534.) 
The exaggerated arch is a secondary and a late result of the paralysis 
and of the equinus and in the slight degrees of deformity, particularly 
in the early stage of the paralysis, it may be absent. 

Etiology. — Equinus in the slighter degrees is perhaps the most 
common of the forms of talipes acquired in later life, and it is not 
at all infrequent as a result of other affections than anterior poliomye- 
litis, although as has been stated, this is by far the most important 
cause. The nerve supply of the anterior muscles of the foot seems par- 
ticularly susceptible, and toe-drop, from neuritis of various types, is 
not at all uncommon. As a sequel of infectious diseases it has been 
alluded to as an explanation of the slight forms of equinus first noticed 
after recovery from such affections. 

Equinus may be a result of disease of cerebral origin, or even in 
rare instances, of pseudo-hypertrophic muscular paralysis or locomotor 
ataxia. It is sometimes the result of habitual posture, as after long 
confinement to the bed for the treatment of fracture or during the 
treatment of hip disease by apparatus ; or the contraction may be an 
effect of voluntary posture, as when the patient habitually walks upon 
the toes because of a short leg. It is a very common result of neglected 
disease at the ankle joint, and it may be a result of direct injury, but 
as of paralysis, so of these less frequent causes it may be said, that 
equinus need never follow if the foot is properly supported. 

The changes in the internal structure of the foot are similar to those 
that follow other forms of deformity ; the tissues on the long side are 
lengthened and attenuated, while those on the short side become con- 
tracted. The bones themselves are but little changed in gross ap- 
pearance, but the articulating surfaces are in abnormal relation to one 
another ; for example, only the posterior part of the astragalus may 
be contained within the malleoli in relation to the tibia, while only 
the lower part of its anterior surface articulates with the scaphoid bone. 
In all cases of equinus there is a strong tendency toward lateral de- 
viation to varus or valgus. This is especially true of cases of par- 
alytic origin. 

Symptoms. — The effects of the deformity vary. If the leg is ac- 
tually shorter than its fellow so that the lengthening caused by the ex- 
tension of the foot is no more than a sufficient compensation ; and if the 
foot is firmly fixed in the deformed position, surprisingly little dis- 



TREATMENT OF ACQUIRED EQUINUS. 613 

comfort or disability may be experienced, other than from corns or 
calluses beneath the metatarsal bones. 

If the leg is not shorter, the additional length caused by the equinus 
must be compensated by a tilting of the pelvis and lateral deviation of 
the spine. This often gives rise to symptoms of discomfort in the 
lumbar region. The gait in this class of cases is always awkward, 
giving the impression as of stepping over an obstacle. 

If the foot is not fixed in the attitude of equinus, that is, if it hangs 
downward when it is lifted, and is forced into a fairly normal attitude 
by the weight of the body, the gait is very awkward because of the inse- 
curity and because of the exaggerated flexion of the knee at each step, 
necessary in order that the pendant foot may not drag upon the ground. 

If the equinus is extreme, the limb is usually flexed at the knee when 
in use ; if the equinus is slight the strain resulting from the limita- 
tion of dorsal flexion is felt at the knee, and in childhood at least, 
there is often a well-marked tendency to over-extension, or recurva- 
tum, caused by the effort to place the sole flat on the ground. 

In the slight forms of equinus, discomfort about the calf is experi- 
enced ; the limitation of dorsal flexion causes a rather shortened stride 
and awkward gait, while an unguarded step, that throws a sudden 
strain upon the rigid heel cord, is felt as a shock and strain through 
the leg and body. Very often the patient complains of pain about 
the metatarsal bones (anterior metatarsalgia), and if the equinus is 
accompanied by a slight degree of valgus symptoms of the weak foot 
may be present. 

The prognosis as to permanent cure depends of course upon the 
cause of the deformity. When it is simply the result of posture or of 
the ordinary form of neuritis and the like, permanent cure may be ex- 
pected. In many of the cases that have followed anterior poliomyelitis, 
recovery, complete or partial, of the original injury to the spinal centers 
has followed ; yet although voluntary control of the muscles has been 
regained it cannot be exercised because the foot is held in the distorted 
'position by the contracted tissues. In such instances practical cure 
may be predicted, if after the over-correction of deformity sufficient 
time is allowed for the over-stretched and atrophied muscles to regain 
their proper length and volume. 

Treatment. — In the rare cases of fixed equinus combined with a 
short leg, in which the patient suffers no symptoms, it is well to allow 
the position to remain, a shoe being so built that the heel may support 
a part of the weight. In the more extreme cases in which the leg is 
short and the foot is atrophied, an extension foot attached after the 
manner of an artificial leg may be worn with comfort and with but 
little evidence of deformity. 

In the ordinary cases whether permanent cure is expected or not, the 
rule holds good that the heel should bear the weight of the body, and 
that the range of dorsal flexion should not be limited when the calf 
muscle retains its power. If the nervous apparatus has received per- 
manent injury, the foot must be supported after the deformity has been 



614 



DEFORMITIES OF THE FOOT 



Fig. 433. 



rectified, but even in this class, the gait may be improved and the discom- 
fort may be relieved by removing the restrictions to normal motion. 

The slight degrees of equinus, such as those that are seen soon after 
the onset of anterior poliomyelitis, may be overcome by simple ma- 
nipulation and retention in a splint or in a plaster bandage. In more 
resistant cases, in older subjects, more force may be exerted ; for ex- 
ample, the patient being seated extends the limb ; the surgeon stands 
in front of him, one hand holds the leg firmly at the ankle, and the 
other grasps the foot ; the weight of the body is then thrown against 

the resistant tissues over and over again 
with as much force as is consistent with 
the comfort of the patient. 

The Shaffer extension brace is also a 
useful appliance, and especially so be- 
cause it may be employed to reduce the 
accompanying cavus at the same time. 

The weight of the body as a means of 
overcoming equinus, when the foot is 
held in its proper relation to the leg by a 
brace, has already been mentioned, but 
this tedious method has but little to 
recommend it in ordinary cases. The 
elastic tension of straps and bands at- 
tached to a brace or to the foot itself by 
means of adhesive plaster is of some ser- 
vice in slight cases, but by far the most 
effective method is the immediate reduc- 
tion of the deformity, by simple forcible 
manipulation under anaesthesia, or by 
tenotomy combined with forcible manip- 
ulation, or by wrenching. 

Immediate Correction of Deformity. — 
Attention has been called to the cavus as an important element in 
equinus, and whenever one attempts to correct the equinus deformity 
by force, the exaggerated arch should be reduced to its normal depth, 
otherwise the foot will appear stunted and deformed. 

One of the most effective procedures is forcible reduction by means 
of the Thomas wrench. (Fig. 417.) The resistant bands of the 
plantar fascia are first divided subcutaneously, the wrench is then fixed 
to the foot and with sudden force, exerted against the resistant tendo 
Achillis, the foot may be straightened, the deep ligaments being ruptured 
or stretched to the proper degree. The tendo Achillis is then divided, 
a wooden foot plate is placed against the sole, and the foot, having been 
dorsi-flexed, is fixed by a plaster of Paris bandage. 

As the patient is encouraged to walk upon the foot as soon as pos- 
sible, the weight of the body forcing the relaxed tissues against the un- 
yielding board incorporated in the plaster completes the flattening of 
the arch. In many of these cases, the knee has been over-extended by 




A brace to prevent foot-drop. One 
upright is often sufficient. 



THE TONIC EFFECT OF IMMEDIATE CORRECTION. 



015 



use in the deformed attitude, so that the habitual flexion necessary to 
bring the dorsi-flexed foot upon the ground, during the two months al- 
lowed for the complete union of the divided tendon, is of benefit, as it 
serves to correct this secondary weakness and deformity. 

The Tonic Effect of Immediate Correction. — The impor- 
tance of the tonic effect of immediate relief of the strain of the de- 
formed position upon the weak anterior group of muscles, together 
with the complete relaxation of the over-stretched tissues, during the 
long rest in the over-corrected position, is not generally appreciated. 
Whenever the weakened muscles, after paralysis, show by tests electri- 
cal or otherwise, that they have recovered their power in part, this 

Fig. 434. 





An effective and inconspicuous support for paralytic toe-drop. An upright of light tempered steel, 
carefully adjusted to the inuer side of the leg and ankle provided with a light calf band. This is 
strengthened by a posterior support attached to the upright. The lower end of the brace is arranged 
as a caliper and is fitted to the metal disc of which two views are shown. A depression is cut in the 
heel of the shoe for the disc as is shown in the diagram. Two strong elastic tapes are sewed to the 
leather of the shoe. These are attached to the studs on the front of the calf band and thus the toe- 
drop is prevented. (See Fig. 435.) 



treatment should be that of selection. The application of electricity 
or other form of stimulation to muscles that are unable to exercise 
their function because of contraction of the opposing tissues is absolutely 
useless. Nor is any form of artificial stimulation equal to that of the 
functional use, which is made possible by the removal of the deformity 
and by the employment of proper support. 

Equinus, more often than any other deformity, is the result of slight 
or temporary disability of the anterior group of muscles, and not infre- 



616 



DEFORMITIES OF THE FOOT. 



Fig. 435. 



quently perfect cure seems to have been attained when the plaster 
bandage is finally removed, usually at the end of two months or more. 
But even in such cases, the application of a simple support to hold 
the foot at a right angle with the leg for several months, is of ad- 
vantage. The after-treatment by massage, muscle-beating, electricity, 
and the like, combined with methodical passive movements to the limit 
of dorsal flexion, to guard against recontraction of the calf muscle, 

should be continued for a long 
time, or until the muscular bal- 
ance has been regained. 

The same form of support is 
necessary in cases of hopeless pa- 
ralysis, to hold the foot at a right 
angle with the leg. The common 
form is a simple steel sole plate of 
sufficient size to support the foot 
and the toes, if their muscles are 
paralyzed, attached to a light up- 
right, provided with a calf-band. 
The upright is usually applied on 
the inner side of the leg, where it 
is least noticeable. At the ankle, 
there is a "stop joint," which 
allows dorsi-flexion but prevents 
the toe-drop. This, when properly 
fitted, can be placed inside the 
ordinary shoe, as the paralyzed 
foot is usually somewhat smaller 
than its fellow. (Fig. 433.) If the 
toes do not need support, the up- 
right can be attached to the out- 
side of the shoe and the foot plate 
may be dispensed with. Or, the 
upright may be concealed by in- 
troducing it inside the shoe to a 
joint sunk in the heel ; the toe- 
drop being prevented by straps passing from the front of the upper 
leather of the shoe, to the calf-band. (Fig. 434.) 

Equinus, due to posture or to disease, may be cured by simple cor- 
rection of the deformity. That due to fracture, when the deformity is 
caused by displacement of the bones, may be treated by direct opera- 
tion or by the removal of a cuneiform section from the anterior surface 
of the tibia above the ankle. (See tendon grafting and arthrodesis.) 




The same appliance (Fig. 434) provided with a 
foot plate of metal or of wood as shown in the dia- 
gram. ..This modification is useful if the paralysis 
is complete or if the foot is much atrophied. 



Acquired Talipes Calcaneus. 

Acquired talipes calcaneus is much less frequent than equinus and it 
is practically always of paralytic origin (anterior poliomyelitis), although 



DEVELOPMENT OF DEFORMITY. 



617 



Fig. 436. 



cases of calcaneus following injury or disease or distortion of the limb 
are occasionally seen. 

There are several varieties or grades of the deformity. In the early 
stage, and especially if all the muscles of the posterior group have 
been paralyzed, the foot assumes an attitude of slight dorsi-flexion and 
the range of plantar flexion is gradually lessened by secondary contrac- 
tions. This variety resembles closely the congenital form. (Fig. 386.) 
In the ordinary and typical form of calcaneus, when fully developed, the 
patient walks, as the name implies, on an elongated heel. The arch of 
the foot is much increased in depth, and the forefoot is atrophied and 
useless. 

Development of Deformity. — The development of the de- 
formity is somewhat as follows : When the tension of the calf muscle 
is removed the os calcis gradually assumes 
an attitude of extreme dorsi-flexion. It stands 
on end so that its posterior surface becomes 
inferior. The posterior projection of the heel 
is lost and it lies in the plane of the atrophied 
calf. The change in the position of the os 
calcis increases the distance from the malleoli 
to the ground, thus calcaneus though in less 
degree than equinus, makes the leg longer. 
The turning of the heel on end, thus lengthen- 
ing one of the terminations of the arch, in- 
creases its depth and at the same time shortens 
the length of the foot so that cavus, in more 
marked degree than with equinus, accompanies 
calcaneus. The cavus is a later complication 
of nearly all cases of paralytic calcaneus. In 
many instances there is no permanent dorsi- 
flexion or elevation of the forefoot, although 
in all, the range of plantar flexion is limited. 
In this class the power in the remaining 
muscles of the posterior group is probably 
sufficient to counteract the contraction of the 

dorsi-flexors. Cavus is thus a direct effect of the displacement of the os 
calcis. If the entire posterior group of muscles is paralyzed, while the 
anterior muscles are unaffected, the foot will be somewhat dorsi-flexed 
and the cavus will be less marked. If the calf muscle only (gastrocne- 
mius and soleus) is paralyzed, the remaining muscles of the posterior 
group will counterbalance the dorsi-flexors, and at the same time in- 
crease the cavus. In some instances the calf muscle is alone affected, 
in others one or more of the anterior muscles may be paralyzed also, in 
which case the foot is usually turned toward varus or valgus. The 
changes primarily caused by the paralysis and by unopposed muscular 
action become fixed by habitual use, and by secondary adaptation of the 
tissues. The heel only, is used in walking, and the area of callus which 
marks the weight-bearing surface becomes much enlarged, while the 




Paralytic calcaueo-varus. 



618 



DEFORMITIES OF THE FOOT. 



forefoot and toes which have but little functional use become atrophied, 
a mere appendage to the enlarged heel. (Fig. 439.) 

Symptoms. — The gait is awkward and inelastic, the patient, who is 
as it were " ham-strung," stamps along upon the insecure support of 
the heel in a manner which is easily recognizable by one familiar with 
the deformity. The changes in the internal structure of the foot, the 
inevitable adaptations to the deformity do not call for especial de- 
scription, the disused bones atrophy together with the other tissues, 
and new articulating surfaces form to accommodate the necessities of 
functional use. 

Treatment. — The essence of successful treatment is prevention. 
When the diagnosis of paralysis of the calf muscle is made, one may 
predict, unless recovery takes place, a deformity such as has been de- 
scribed. This deformity may be prevented by proper support, by 



Fig. 43 1 ; 



Fra. 438. 





Judsoa's brace for calcaneous deformity. 



massage and methodical stretching of the tissues that have a tendency 
to contract. The form of brace used for walking and support, should 
be provided with a sole plate, upright and calf-band, as already de- 
scribed in the treatment of paralytic equinus. If motion is allowed 
at the ankle it should be in plantar flexion only, the stop being the 
reverse of that used in equinus, or as this form of check entails much 
strain upon the brace, the joint may be omitted as in that form used 
by Judson. (Figs. 437, 438.) Thus the strain, removed from the 
weakened tissues, is borne by the anterior surface of the leg. Other 
forms of braces are sometimes employed, provided with elastic bands 
to supply the place of the calf muscle, but as a rule the improvement 
in gait hardly compensates for the trouble in adjustment or the con- 
spicuousness of the appliance. 

The most important part of the actual deformity of calcaneus is the 



WILLETT'S OPERATION FOR CALCANEUS. 



619 



cavus, in great part due to the changed position of the os calcis ; and 
in confirmed cases it is practically impossible to reduce this except in 
part, because the loss of resistance of the tendo Achillis takes away 
the point of fixation, against which effective force can be exerted. If 
the deformity is not marked, the foot may be drawn as far as possible 
toward equinus and fixed in a plaster bandage, the sole part being 
strengthened by the insertion of a thin board. Upon this the patient 
may walk, the heel being built up with cork wedges to make the sole 
level. When the contraction of the anterior tissues has been overcome, 
the brace is applied and the usual treatment of manipulation and mas- 
sage is continued. 

The method of pro- Fig. 439. 

longed fixation in the atti- 
tude of equinus by means 
of the plaster bandage is 
often very efficacious in 
childhood and cures of ap- 
parently hopeless cases by 
this means have been re- 
ported. 1 

Operative Treatment. — 
In more extreme cases im- 
mediate reduction of the 
deformity under anaesthe- 
sia . may be attempted. 
The plantar tissues, more 
particularly the plantar 
fascia, may be divided 
subcutaneously or by open 
incision and by forcible 
manipulation or wrench- 
ing the sole may be some- 
what lengthened and the 
heel pushed somewhat up- 
ward and backward, so 
that the foot may be fixed 
in a plaster bandage in slight plantar flexion. In the reduction of the 
deformity one must not force the forefoot downward as this would 
simply increase the cavus, but whatever correction is accomplished 
should be by means of elevation of the os calcis and elongation of the 
tissues of the sole of the foot. 

In some instances the improved position of the os calcis may be 
confirmed by shortening the tendo Achillis, as first performed by AVil- 
lett, of London. 2 

Willett's Operation for Calcaneus. — A Y-shaped incision about two 
inches in length is made through the tissues down to the tendon. At 

JGibney, Trans. Am. Ortli. Ass'n, Vol. XIII., 1900. 
2 St. Bart's Hosp. Keports, Vol. XVI., 1880, p. 309. 




Paralytic calcaneus, showing secondary changes in contoui 



620 



DEFORMITIES OF THE FOOT. 



the lower or vertical part of the incision, which is continued down to 
the tuberosity of the os calcis, the tendon is dissected free from the sur- 
rounding parts. It is then divided in an oblique direction from within 
outwards, and downwards, and the heel having been pushed upward as 
far as possible, the divided ends are overlapped and sutured ; the flap 
of skin is drawn downwards at the same time, so that the Y-incision is 
converted into the shape of a V. According to Mr. Willett's original 
directions, deep sutures are passed through the skin flaps and through 
the tendon on either side, so that all the tissues are united. The foot 

is then fixed in a plaster bandage, and 
Fig. 440. the patient is allowed to walk about 

wearing a high heel to compensate for 
the elevation of the sole. 

The operation is of value in those 
cases in which some power remains in 
the calf muscle, which is thus made 
serviceable. 

In cases of complete paralysis the 
position of the foot may be temporarily 
improved, but unless proper support is 
used afterward the tissues will stretch 
under the strain of use ; thus the treat- 
ment should always be supplemented by 
a brace of the character already de- 
scribed. (Fig. 438.) 

Astragalectomy and Backward Dis- 
placement of the Foot. — -In cases of con- 
firmed calcaneus or calcaneus combined 
with lateral deformity, varus or valgus, 
removal of the astragalus may be in- 
dicated. This operation permits the 
direct contact with the os calcis, thus 




Paralytic varus and valgus. (Gibney.) 



malleoli to be brought into 
increasing the security of the foot. 

The astragalus may be removed by a long, curved, external incision 
passing from the tendo Achillis just below the outer malleolus to the 
front of the joint. The peronei tendons are divided, the foot is dis- 
placed inward and the astragalus is removed. The articulating sur- 
faces of the leg bones and of the os calcis, are denuded of cartilage ; 
the tendo Achillis is shortened and to it the peronei tendons are at- 
tached if the muscles are active. The entire foot is then displaced 
backward so that the denuded malleoli overlap the anterior extremity 
of the os calcis. The object of this procedure is to throw the weight 
of the body upon the center of the tarsus ; thus the deformity is reduced 
and the stability of the foot is increased. The wound is closed and 
the foot is fixed in plaster of Paris. As soon as possible the patient 
uses the foot in standing and walking. Ultimately apparatus may be 
dispensed with, but the Judson brace may be used for a time with ad- 
vantage. This operation has been performed in many instances by 



Fig. 441. 



Wf'D; 






GASTRGJCNEMIUS 



'■'■'7, v 



m\] 1U 



The muscles and tendons on the front of the 
leg. (Testut.) From Gerrish's Anatomy. 



The muscles and tendons on the back of the 
leg. (Testut.) From Gerrish's Anatomy. 



622 



DEFORMITIES OF THE FOOT. 



Fig. 443. 



the author, for whom it is now the treatment of choice in this type of 
deformity. (Fig. 438.) By it the usefulness of the foot is greatly 
increased and its appearance very much improved. 

Acquired Calcaneo-Valgus and Calcaneo-Varus. 

In many cases, the foot deformed as a result of paralysis of the calf 
muscle is in addition turned in a lateral direction, so that the weight 

of the body falls to the inner or outer 
side of its center. (Fig. 436.) 

Calcaneo-valgus in which the foot is 
turned outward and upward so that the 
patient walks on the inner side of the 
heel or even on the inner ankle is not un- 
common. It is usually a result of more 
extensive paralysis than simple calcaneus. 
For example, all the muscles about'* the 
foot may be disabled except the peronei, 
or in cases of a milder type the tibialis 
anticus may be the only muscle of the 
front of the foot that is paralyzed. 

Treatment. — When the foot inclines 
toward calcaneo-valgus it is difficult to 
hold it in proper position. The usual 
method is to apply the brace, used for 
ordinary calcaneus, with the upright on 
the outer side of the foot ; the ankle and 
arch are then held against it by means of 
a leather strap. Another form of brace 
is provided with an upright on either 
side of the leg, the outer being slightly 
longer than the inner so that the sole plate 
is tilted inward, or as it were supinated ; 
thus the weight is guided towards and 
balanced on the outer side of the foot. 
It must be borne in mind that other mus- 
cles of the limb are often paralyzed, so 
that the deformity of the foot may be but 
a part of more general distortion, so that 
the foot brace is often combined with ap- 
paratus for the support of the leg. (Fig. 
314.) 

In the more extreme cases the deform- 
ity may be reduced, and the stability of the foot may be increased by 
the removal of the astragalus in the manner described. 

Calcaneo-varus is a much less serious affection, since the foot may be 
more easily supported. A brace, such as is used in the treatment of 
ordinary varus, without motion at the ankle, or provided with a reverse 
stop, is ordinarily employed. 




Tendons in the right sole. (Testut. ) 
From Gerrish's Anatomy. 



ACQUIRED TALIPES EQUINO-VARUS. 623 

Acquired Talipes Equino -varus. 

Talipes equino-varus is, in the acquired as in the congenital form, 
the most common of the deformities of the foot. (Fig. 440.) 

The tendency of simple equinus is usually toward varus, because in 
plantar flexion the foot is slightly adducted, and because the outer side 
of the foot is shorter than the inner side so that in walking with the 
foot extended the tendency of the foot is to turn somewhat inward. 
Equino-varus is usually preceded by equinus, and the etiology of the 
one will serve for the other. (Page 612.) 

In certain cases the varus is more marked than the equinus, as for 
example when the abductors of the foot are paralyzed while the adduc- 
tors retain their power ; or in cases of direct injury as in fracture at the 
ankle ; or when the growth of the tibia has been arrested as the result 
of injury or disease. 

A detailed account of the appearance and effect of the deformity is 
unnecessary. In the early stage of the paralysis it may be reduced 
easily ; the foot must then be supported by a brace, of which the Taylor 
olub foot apparatus is the type. (Fig. 410.) During the night the 
over-corrected attitude may be assured by a strap running from the up- 
right to the sole plate. 

If the deformity is fixed it should be reduced and over-corrected by 
forcible manipulation under anaesthesia. Division of resistant parts is 
less often necessary than in the congenital form, but it may be re- 
quired in neglected cases. The over-corrected position should be re- 
tained until time has been allowed for the recontraction of the length- 
ened tissues ; for as has been mentioned in the treatment of equinus, 
over-correction and rest is by far the most effective treatment that can 
be applied to a weak or paralyzed part. A support is then used of the 
character indicated. 

Astragalectomy and cuneiform osteotomy are rarely indicated, but 
the latter operation is sometimes of service in checking the tendency 
toward recurrence of deformity, which is more marked after over-cor- 
rection in the paralytic than in the congenital talipes. 

Acquired talipes equino-valgus is much less frequent than the preced- 
ing deformity. Simple equino-valgus is usually the result of primary 
paralysis of the tibialis anticus, the most powerful of the dorsal flexors ; 
thus the foot is drawn somewhat outward when dorsi-flexed, while the 
metatarsal bone of the great toe, having lost the support of the tibialis 
anticus muscle, falls downward and is drawn outward by the peroneus 
longus. In this type one's attention is often attracted by the peculiar 
appearance of the great toe, which is deformed somewhat like a ham- 
mer toe by the over-action of the extensor longus pollicis, in its attempt 
to take the place of the tibialis anticus. The equinus is usually slight 
and is secondary to the valgus. Treatment may be begun by placing 
the foot in a plaster bandage in an attitude of varus and allowing the 
patient to walk upon it until the tendency toward deformity has been 
overcome. A support with the catch, as for toe-drop, is applied to the 



624 DEFORMITIES OF THE FOOT. 

shoe, and the tendency toward valgus is checked by raising the inner 
border of the sole or by the use of a sole plate, as in the treatment of 
the simple weak foot. (Fig. 440.) 

Acquired simple talipes valgus, from paralysis of the tibialis anti- 
cus and posticus is rare. Talipes valgus, as when the foot is dislo- 
cated outward, in cases of complete paralysis of all its muscles, may 
be considered as a variety of daugle foot. 

Traumatic valgus and equine- valgus, caused by fracture at the ankle 
(Pott's fracture) may be treated by osteotomy of the tibia above the 
ankle. By this means the proper relation of the leg to the foot may 
be restored in many instances. Equino-valgus of slight degree is not 
uncommon after tuberculous or rheumatic disease at the ankle or at the 
astragalo-scaphoid joints. This is practically one variety of the weak 
foot. 

Talipes valgus, sometimes called spurious valgus, the simple weak 
or flat foot, has been described elsewhere (Chapter XX.). 

Talipes caused by cerebral disease, whether of the paraplegic or the 
hemiplegic type, is almost always of the form of equino-varus in early 
childhood. In adolescence the deformity may be equino-valgus or 
even calcaneo- valgus if there is extreme flexion at the knee. The 
hemiplegic form of talipes is much more rigid and unyielding than the 
paraplegic type. The treatment of spastic paralysis, of which the de- 
formity is a part, is discussed elsewhere (Chapter XVIII.). The 
deformity must be corrected by the ordinary methods. In many in- 
stances, when the contractions are not marked, mechanical treatment 
is unnecessary. 

Hysterical equino-varus, or other form of deformity, is not espe- 
cially rare. The diagnosis may be made from the other symptoms of 
hysteria, from the history of the onset and duration of the distortion, 
and from the appearance of the deformity, which is evidently merely 
an assumed posture. (See page 471.) 

Tendon Transplantation for the Relief of Paralytic Talipes. 

When one or more of the muscles are paralyzed the unbalanced 
action of those that remain tends to distort the foot. The object of 
the brace, in such cases, is to hold the foot so that the muscular trac- 
tion, however applied, can move it only in the proper directions. 
The object of tendon or muscle transplantation is to utilize the mus- 
cular power that remains. Thus by giving an active muscle a new 
point of attachment where it may be of greatest service the brace may 
be dispensed with, or made less burdensome. 

Tendon transplantation is, as the name implies, the operation of at- 
taching the tendon of a living to that of a paralyzed muscle. The 
first operation was performed by Xicoladoni in 1882, 1 for the relief of 
paralytic calcaneus. The tendons of the peroneus longus and brevis 
were divided behind the external malleolus, and the proximal ends 

1 Archiv f. Klin. Chir., 3, 27, S. 660, 1882. 



TENDON TRANSPLANTATION 



625 



Fig. 444. 



united to the distal extremity of the divided tendo Achillis. The re- 
sult is said to have been satisfactory. 

The first operation on the front of the foot was performed by Parish, 1 
of New York, for the relief of paralytic valgus, by sewing the tendon 
of the extensor proprius pollicis to that of the paralyzed tibialis anticus, 
without division of either tendon. In more recent years the field of the 
operation has been extended by Drobnik, of Posen, 2 Goldthwait, 3 of 
Boston, and others, to include almost every possible combination of 
tendons and muscles. 

Tendon transplantation is most effective from the curative stand- 
point when but one muscle of the anterior leg group, for example an 
adductor or abductor, is para- 
lyzed. The most common form 
of this milder type is paralysis 
of the tibialis anticus. As this 
muscle is the most powerful 
dorsal flexor and adductor of 
the foot its loss is followed by 
secondary equino-valgus. In 
Parish's operation the tendon of 
the adjoining extensor proprius 
pollicis was simply attached to 
that of the tibialis anticus, but 
as the extensor of the great toe 
is a very weak muscle, its power 
is hardly sufficient for the double 
task. A more efficient proced- 
ure is to split the tendon of the 
paralyzed muscle. The outer 
half is then separated from its 
muscular attachment, and the 
distal extremity is carried across 
the foot and is sutured to all the 
other tendons. The proprius 
pollicis is then attached to the 
inner half. In cases of longer 
standing and more marked de- 
formity it is well to reduce the 

power of the abductors by cutting the tendon of the peroneus tertius 
from its insertion. This is then drawn beneath the other tendons 
and is attached to that of the tibialis anticus. All of the tendons on 
the front of the ankle may then be sutured to one another, so that all 
may act as direct dorsal flexors. 

If varus has resulted from paralysis of the peroneus tertius or 
brevis, or because of weakness of the extensors of the toes, while the 




Paralvtic equino-varus before operation. 
(See Fig. 4J5.) 



»N. Y. Med. Jour., Oct. 8, 1892. 

2 Centb. f. Chir., N. 7, July, 1894. 

3 Trans. Am. Orth. Ass'n, Vol. VIII. , 1896. 



40 



626 



DEFORMITIES OF THE FOOT. 



the tibialis anticus retains its power its tendon may be split, the outer 
half having been separated at the distal end may be passed beneath the 
other tendons to be attached to the peroneus tertius, or a new attach- 
ment to the tissues on the outer border of the foot may be made. 
(Fig. 445.) 

Every variety of combination has been employed. The tendon of 
the peroneus longus has been brought across the foot and attached to 
the tibialis anticus for the relief of valgus. The tendons of the flexor 
longus pollicis and of the peroneus brevis have been attached to the 
tibialis posticus and a portion of the inner part of the tendo Achillis 
has been utilized for the purpose of overcoming the same deformity. 

Other operations on the back of the leg have been practically that 
of Nicoladini, the transplantation of the two peronei muscles into the 

Fig. 445. 




Paralytic equino-varus cured by operation, showing power of dorsal flexion (one half of the 
tendon of the tibialus anticus attached to the periosteum of the outer border of the foot). Operation 
July 19, 1898. The direct union of tendons to periosteum at the most advantageous point, has been 
urged recently by Lange (Ueber Periostale Schnenverplanzung bei Lahmung, Munch, med. Woch., 
No. 15, 1900). 



tendo Achillis ; or, as modified by Goldthwait, the tendon of the per- 
oneus longus was inserted into the tendo Achillis and the brevis was 
transplanted into that of the flexor longus pollicis. 

The operation of tendon transplantation should not be performed 
until the recovery from the paralysis is considered impossible. The 
incision should be sufficiently long to expose the tendon and the mus- 
cular substance. The paralyzed muscle is quite different in color from 
the normal, being dull reddish yellow, and the tendon is usually dull 
white in place of the silvery glistening color of the normal tendon. 
The splitting of the tendon should be begun high up, including, in 
some instances, muscle substance, and in joining the splices, as much 



TEND ON TRANSPLA NT A TION 



627 



surface as possible of each splice should be apposed because the tendons 
do not readily unite. 

Fine silk is usually employed for suturing. The tendon sheaths are, 
as far as possible, closed by fine catgut and the skin incision with the 
same material. Before the operation is performed, all resistance to 
normal motion should be overcome by force, and by division of the 
contracted parts, if necessary. The attachment of the muscles or ten- 
dons should be made while the foot is held in proper position, and in 
many instances, it is well to cut and overlap the paralyzed tendons to 
aid in retaining the foot in the improved attitude. 

After the operation is completed, the foot should be fixed in a plas- 
ter bandage, in the over-corrected position, for several weeks or more. 

Fig. 446. 




Talipes equiuo-valgus after treatment by tendon transplantation. The tendon of the peroneus ter- 
tius was attached to the overlapped and shortened tendon of the tibialis anticus. All the tendons 
on the front of the foot were then united, so that all might serve as dorsal flexors. 

As a rule, the foot should be supported by a brace until it is evident that 
the union of the parts is firm, and until the functional result is assured. 
The prognosis will depend entirely upon the character of the par- 
alysis. If the tibialis anticus is alone affected, sufficient power may 
be borrowed from the other muscles to lift the foot at least sufficiently 
to prevent awkwardness of gait, and to restrain deformity. Even 
more favorable is the prospect for the relief of varus, caused by weak- 
ness of the abductors, but it is impossible for weak muscles like the 
peronei, to supply the place of the great calf muscle or even to restrain 
the deformity of calcaneus. The power obtained from the peronei 
however, which has become useless and even harmful because it draws 
the foot into deformity, may be sufficient to hold the heel in proper 



628 DEFORMITIES OF THE FOOT 

position and at least to aid the brace in retaining the foot in a normal 
attitude. The origin and insertion of the muscles, are shown in Figs. 
340—350 inclusive. 

The relative strength of the muscles, as well as their function, should 
be considered in selecting grafts, and in prognosis also. According to 
Fiek, it is as follows, in kilogrammeters (see page 503) : 

Back of the Leg. 

The calf muscle — gastrocnemius and soleus 8.21 

Tibialis posticus o. 40 

Peroneus longus 0.44 

Flexor com. digitorum 0.37 

Flexor longus pollicis ..0.82 

10724 
Front of the Leg. 

Tibialis anticus 1.61 

Extensor proprius pollicis 0. 39 

Extensor longus digitorum 0. 72 

Peroneus brevis 0.31 

Peroneus tertius 0. 20 

3T23 

The importance of the calf muscle on the back, and tibialis anticus 
on the front of the leg, is apparent. The former is nearly four times 
as strong as the combined posterior group, the latter equal to all the 
others on the front of the leg. 

It has been claimed that the transplanted muscle may become hyper- 
trophied and that its strength may increase sufficiently to carry out its 
new function, but this is somewhat doubtful. 

Direct transplantation of muscles on the same principle as tendon- 
grafting, has also been performed by Drobnik, Goldthwait and others ; 
for example, the sartorius, the gracilis, or the tensor vaginae femoris 
may be transplanted into the substance of the quadriceps extensor 
muscle. Drobnik has suggested the possibility of regenerating the 
paralyzed muscle by thus engrafting a portion of one that is still 
active, but this is a possible rather than a probable outcome. 1 

The principle of the operation applies of course to other parts of the 
body as well, but the opportunities for its application are far less fre- 
quent than in the lower extremities. The transplantation of certain 
of the over-active flexor muscles to the extensor aspect of the limb is 
sometimes of service in overcoming the deformities of spastic paraly- 
sis. The operation may be of especial service in the treatment of de- 
formity of the hand in hemiplegia. (See page 464.) 

The operation of tendon transplantation is often indicated, as is illus- 
trated by the fact that it has been employed in fifty-five instances at the 
Hospital for Ruptured and Crippled during the past year. The author 
has always employed long incisions to thoroughly expose the muscles 
and fine silk for tendon sutures. Tendon transplantation has been 
combined, as a rule, with tendon shortening, and in many instances all 

1 It is impossible to formulate rules for tendon transplantation. The first essential 
is exact knowledge of the degree and distribution of the paralysis in the case to be 
treated, and of the function and strength of the muscles that remain. One may then 
decide how this power may be best applied, in order to balance the foot and to over- 
come deformity. 



ARTHRODESIS. 



629 



Fig. 44/ 



the tendons on the front of the foot have been sutured to one another, 
so that all the power might be utilized for dorsi-flexion. In certain 
cases the transplanted tendon may be united directly to the periosteum 
on the inner or on the outer side of the foot, instead of to the para- 
lyzed tendon. Tendon transplantation may be combined also with other 
operations, such as astragalectomy, cuneiform osteotomy and the like. 

Tendon Splicing. — Division and 
over-lapping of the tendons of para- 
lyzed muscles may be employed with 
advantage in certain instances. For 
example, in complete paralysis of all 
the dorsal flexors of the foot, each ten- 
don may be shortened and attached to 
the anterior ligament, thus the toe-drop 
may be remedied, or reduced to such 
an extent that the deformity may in- 
terfere but slightly with locomotion. 
As a rule however apparatus must be 
employed to prevent a recurrence of 
the deformity. 1 

Arthrodesis. 

Arthrodesis, the removal of the car- 
tilaginous surfaces of adjoining bones 
and thus inducing anchylosis for the 
relief of paralytic deformities of the 
foot, was first performed by Albert, 
of Vienna, in 1878. As applied to 
the foot, it is usually limited to those 
cases in which practically no muscular 
power remains, the so-called dangle foot. 

It may be of service also in cases of less disability as in equinus or cal- 
caneus, when the patient is unable to provide himself with apparatus. 

The operation consists in opening the joint and removing the carti- 
lage from the apposed surfaces of the bones, then sewing or nailing 
them to one another, or simply fixing the parts in a plaster bandage 
until union has taken place. If the case is one of simple calcaneus or 
equinus, without lateral deviation, the operation may be limited to the 
ankle joint which may be opened from the back or front or side, as 
seems preferable. The cartilage is usually removed with a sharp spoon, 
and at the same time the relaxed tissues may be shortened after the 
Willett method, if the deformity be calcaneus ; or the tendons on the 

' Besides those mentioned in the text, the following are the more important articles 
on the subject of tendon transplantation : Hacker, Wiener Med. Presse, 1886. Phocas, 
Revue d'Orthopedie, T. 4, 1893. Winkleman, Zeits. fur Chir., Ed. 39, S. 109. 
Milleken, N. Y. Medical Record, Dec, 1895. Ghillini, Zeits. fur Orth. Chir., Bd. 4, 
1896. F. Franke, Archivfiir Klin. Chir., Bd. 52, H. 1 ; Bd. 57. Eulenburg, Deutsche 
med. Wochens., N. 14, 1898. Goelet, Zeits. fur Orth. Chir., Bd. 7, H. 1, 1899. 
Hoffa, Berlin, klin. Wochens., X. 30, 1899. 




A brace with a " limited " joint allow- 
ing slight motion at the ankle for paral- 
ysis or weakness. # 



630 DEFORMITIES OF THE FOOT. 

front of the foot may be similarly shortened with the aim of lifting the 
toes to the proper level, if they are depressed. If, as in many in- 
stances, the deformity is equinuo-varus or valgus, the simple fixation 
at the ankle joint will be insufficient and it must be supplemented by 
arthrodesis of one or more of the anterior articulations. 

In cases of calcaneo-valgus, the removal of the astragalus will be 
found to be a useful operation, since it improves the stability of the 
joint, and the limitation of motion is usually sufficient to prevent de- 
formity. If the astragalus is not removed, the operation must include 
the fixation of the astragalo-scaphoid, and the medio-tarsal as well as 
of the ankle joint, and, if toe-drop is extreme, of the tarsal joints also. 

The method of operating depends upon the deformity. In simple 
arthrodesis of the ankle joint for toe-drop, the joint may be opened by 
a perpendicular incision over the front of the ankle. 

For calcaneus, the posterior incision may be employed, if it is in- 
tended to shorten the tissues after the Willett method in connection 
with the arthrodesis. 

Both the ankle and the calcaneo-astragaloid joints can be opened 
from the back, although the upper one may be more easily reached 
from the front. If it is necessary to fix the medio-tarsal joint as well 
as the ankle joint, a curved incision may be made beneath the inner 
malleolus to the middle of the foot ; or if the foot is in varus, the incision 
may be made on the outer side. The cartilaginous surfaces of the 
bones must be completely removed if firm anchylosis is to be obtained. 
The parts may be fixed with sutures or nails, but this is unnecessary 
if accurate opposition can be obtained. The foot is fixed by means of a 
plaster bandage in the line of the leg, slightly dorsi-flexed, and as soon 
as possible the patient is encouraged to use the part. 

The improvement in the gait, obtained by the rectification of de- 
formity and by fixation of the foot, is often very marked, and in many 
instances support may be discarded. But, in early childhood at least, 
the patients should, if possible, be kept under observation, in order that 
support may be applied if the deformity shows a tendency to recur. 

Arthrodesis is also performed at the knee and at other joints for 
the purpose of fixing the part in a useful attitude. In certain in- 
stances, the operation is indicated. It is, of course, limited to cases of 
hopeless paralysis and it is more suitable to the older than the younger 
class of patients. 1 

1 The more important articles on arthrodesis are the following : Bidone, Archiv 
di Ortoped., Fasc. 6, 1894. Samter, Centb. fur Chir., 1895, N. 21, S. 497. Karewski, 
Centb. fur Chir., 1895, N. 25, S. 593. Jones, The International Medical Annual, 
1895, p. 407. Karasiewicz, Inaug. Diss. Konigsberg, 1894. Broca, Revue d'Ortho- 
pedie, Nov., 1894. Roersch, Revue de Chir., 1892, No. 6. Kirmisson, Revue d'Or- 
thopedie, N. 2, 1896. Popper, Wiener klin. Rundschau, N. 20, 1900. 



INDEX. 



ABSCESS in extra-articular tuberculous 
joint disease, 199 
in hip disease, see Abscess in Tuber- 
culous Disease Hip Joint, 255 
pelvic, in lumbar Pott's disease, 40 
in Pott's disease, 87 

in different regions, 88 
treatment of, 89 
in sacro-iliac disease, 119 
secondary, in tuberculous joint dis- 
ease, 200 
in thoracic region, 49 
in tuberculous disease of ankle joint, 
334 
of hip joint, 285 

frequency of, 285 
significance of, 286 
treatment of, 287 
by aspiration, 

288 
by incision, 288 
by injection, 
288 
of knee joint, 318 

statistics of, 318 
treatment of, 318 
by aspiration, 

318 
by incision, 318 
of shoulder joint, 350 
Absent patella, 329 
Achillo-bursitis, 544 

etiology of, 545 
pathology of, 545 
symptoms of, 545 
treatment of, 546 
brace in, 546 
operative, 546 
posterior, 547 

symptoms of, 547 
treatment of, 547 
Achillodynia, see Achillo-bursitis, 544 
Achondroplasia, see Foetal Khachitis, 367 
Acquired genu recurvatum, 332 
Acquired talipes, 609 
calcaneus, 616 

astragal ectomy for, 620 
development of deformity of, 

617 
symptoms of, 618 
treatment of, 618 

operative, 619 
Willett's operation for, 619 
development of deformity in, 609 



Acquired talipes, differential diagnosis in, 
610 
equino-valgus, 623 

treatment of, 623 

equino-varus, 623 
treatment of, 623 

cuneiform osteot- 
omy in, 623 
equinus, 611 

etiology of, 612 
immediate correction of de- 
formity of, 614 

Thomas wrench 
for, 614 
tonic effect of, 615 
prognosis, 613 
symptoms of, 612 
treatment of, 613 

Shaffer extension brace 
in, 614 
etiology of, 609 
Acquired torticollis, 479 
Acromegalia, 371 
diagnosis of, 371 
symptoms of, 372 
Actinomycosis of spine 108 
Acute torticollis, 479 
Amputations, spontaneous, congenital, 608 
Anchylosis, 218 
etiology, 218 
pathology, 218 
prevention of, 219 
treatment of, 219 

by forcible correction, 220 
operative exploration in, 220 
by passive motion, 220 
Ankle joint, tuberculous disease of, 334 
sprain of, 342 
chronic, 344 

treatment, 345 
symptoms, 342 
treatment, 343 

by plaster bandage, 343 
by plaster strapping, 343 
Anterior bow leg, 428 

symptoms of, 429 
treatment, 429 
Anterior curvature of tibia, see Anterior 

Bow Leg, 428 
Anterior dislocation of hip, 380 
Anterior displacement of the tibia, see 

Congenital Genu Recurvatum, 328 
Anterior metatarsalgia, 538 

complications of, 542 



632 



INDEX. 



Anterior metatarsalgia, etiology of, 538 
influence of shoe in causing dis- 
ability and pain in, 541 
pathology of, 538 
treatment of, 542 
brace for, 543 
support in, 543 
Anterior poliomyelitis, acute, 440 

causes of deformity of, 445 
deformities of upper ex- 
tremity in, 447 
of neck in, 447 
of trunk in, 448 
secondary in, 449 
diagnosis of, 443 

differential, 443, 444 
etiology, 441 
pathology, 440 
prognosis, 444 
retardation of growth in, 449 
statistics of, 441 

tables of, 441, 442 
symptoms of, 442 
treatment of, 450 

mechanical principles 

of, 450 
prevention of deformity 
in, 450 
arthrodesis in, 456, see Talipes 
osteotomy in, 457 
paralysis in, 444 

of anterior muscles of leg, 
in 450, see Talipes 
paralysis of arm in, 455 
electrical test for, 445 
muscles of hip in, 454 
of posterior muscles of leg 

in, 451 
of thigh muscles in, 451 
paralytic scoliosis in, 454 
reduction of deformity of, 455 

by braces, 456 
tendon transplantation in, 456 
treatment, operative, 455, 457 
Arborescent synovial tuberculosis, 201 
Arthectomy in tuberculous disease of knee 
joint, 319 
advantage of, 319 
results of, 319 

statistics of, 31 9 
table of short- 
ening, 320 
Arthritis, acute, of infancy, 211 

deformans, see Osteo-arthritis, 212 
following infectious disease, 210 

operative intervention 

in, 211 
treatment of, 211 
typhoid fever, 211 

statistics of, 211 
gonorrhoea^ 208 

statistics of, 208 
symptoms of, 208 
treatment of, 210 
varieties of, 209 
infectious, of knee joint, 325 



Arthritis, infectious, treatment of, 325 
puerperal, 210 

rheumatoid, of knee joint, 325 
of spine, 111 

chronic rheumatoid, 113 
treatment of, 111 
tuberculous, acute, 212 
Arthrodesis, 629 

description of operation, 629 
for toe drop, 630 

in treatment of anterior poliomyelitis, 
456, see Talipes 
Astragalectomy in treatment of calcaneus, 
620 
in treatment of club foot, 598 
Asymmetrical development, 189 
Ataxia, hereditary, 468 

symptoms of, 469 
Atrophy, muscular progressive, 466 

BACK knee, see Genu Eecurvatum, Ac- 
quired, 332 
lower part of, pain in, 116 

treatment of, 116 
Bands, constricting, congenital, 608 
Bending of neck of femur, see Coxa Vara, 

392 
Bier' s treatment, see Venous Stasis, 205 
Bilateral coxa vara, 397 

dislocation of hip, 379 
Billroth splint in treatment of tuberculous 

disease of knee joint, 313 
Bow leg, see Genu Varum, 405, 423 

anterior, 428 
Braces in treatment of lateral curvature 

of spine, 148, 176 
Bradford frame, 60, 271 

in treatment of rhachitis, 366 
Bursa? in popliteal region, 326 
Bursitis, chronic, at shoulder, 359 
prepatellar, 325 
pretibial, 326 

pALCANEO-BURSITIS, 547 

\J symptoms of, 547 

treatment of, 547 
Caliper brace in treatment of tuberculous 
disease of knee joint, 317 

description of, 317 
Calot's operation, 101-103 
Campbell brace, in treatment displacement 

semilunar cartilage in knee, 327 
Caput quadratum, 363 
Cerebral paralysis of childhood, 459 
Cervical opisthotonos, 491 
Charcot's disease, 217 

diagnosis, 217 

distribution, 217 

pathology, 217 

statistics of, 217 

symptoms, 217 

treatment, 218 
Chest, circumference of, table of, 190 
deformities of, 186 
flat, 186 

treatment of, 186 



INDEX. 



633 



Chest, funnel, 187 
pigeon, 186 

treatment of, 187 
Chondrodystrophia, see Foetal Rhachitis, 

367 
Clavicle, absence or defect of, 188 
acquired luxation of, 188 
treatment of, 188 
Club hand, 434 

etiology, 434 
statistics of, 435 
treatment of, 436 
operative, 436 
Club foot, astragalectomv in treatment of, 
598 
confirmed, correction of, method 

Julius Wolff, 593 
congenital, anatomy of, 569 
symptoms of, 572 
treatment of, 572 
cuneiform osteotomy in treat- 
ment of, 599 
division of the tendo Achillis in 
treatment of, 592 
forcible correction of deformity of, by 
osteoclasts, 596 
by Phelps' opera- 
tion, 596 
by Thomas method, 
595 
manual correction of, 585 
hysterical, 470 

differential diagnosis of, 471 
infantile, principles of treatment of, 
573 
rectification of deformitv of, 

574 
treatment of, mechanical, 574 
by plaster bandage, 

575 
by splints and 
braces, 577 
retention brace in, 581 
tenotomy in, 579 
malleotomy in treatment of, 591 
mechanical rectification of de- 
formity of, 600 
Judson brace for, 
600 
osteotomy in treatment of, 598 

secondary treatment of, 600 
rapid correction of deformity of, 585 
subcutaneous tenotomy in treat- 
ment of, 591 
treatment of, division of plantar 
fascia in, 593 
of tibialis anticus in, 593 
posticus in, 593 
Congenital absence of fibula associated 
with talipes 
equino - val- 
gus, 606 
etiology of, 607 
statistics of, 606 
treatment of. 
607 



Congenital absence of tibia associated with 
talipes var- 
us, 607 
prognosis of, 

607 > 
statistics of, 607 
treatment of, 
607 
club foot, 569 
contraction of fingers, 437 
treatment of, 437 
at knee, 332 
deficiency and hypertrophy, 607 
deformities of elbow, 433 

at wrist, 434 
dislocation of hip, see Hip Joint, Con- 
genital Dislocation of, 373 
of shoulder, 430 

treatment of, 430 
displacement of patella, 329 
elevation of scapula, 185 
etiology of, 185 
treatment of, 186 
genu recurvatum, 328 
hallux varus, see Pigeon Toe, 551 
lateral curvature of spine, 135 
cedema of feet, 608 
talipes calcaneus, 604 

statistics of, 604 
treatment of, 604 
equinus, 604 

statistics of, 604 
valgus, 605 

statistics of, 605 
varus, 603 
torticollis, 475 
Constricting bands, congenital, 608 
Contracted foot, see Hollow Foot, 534 
Contraction of fingers, congenital, 437 
treatment of, 437 
confirmed club foot, method Julius 
Wolff", 593 
Coxa vara, 392 # 

bilateral, 397 
diagnosis of, 398 
etiology of, 393 
mechanical effects of, 394 

predisposition to deformity 
of, 393 
pathology of, 393 
physical effects of, 396 
statistics of, 394 
table of, 395 
symptoms of, 394 
traumatic, 402 

diagnosis of, 402 
treatment of, 402 
treatment of, 399 

apparatus in, 400 
operative, 400 

cuneiform osteotomy, 
_ 401 

linear osteotomy, 400 
unilateral, symptoms of, 396 . 
Craniotabes, 363 
Cretinism allied to foetal rhachitis, 367 



634 



INDEX. 



Cubitus valgus, 433 
varus, 433 

Cuneiform osteotomy, in treatment of an- 
terior bow leg, 429 
of club foot, 599 
of coxa vara, 401 
of genu valgum, 422 
of hallux valgus, 554 
of talipes, 599 

Cysts in popliteal region, 326 

DEPRESSION of neck of femur, see 
Coxa Vara, 392 
Development, asymmetrical, 189 

normal, tables of, 190 
Diagnosis of Achillo-bursitis, 545 
of acquired talipes, 610 
of acromegalia, 371 
of actinomycosis of spine, 108 
of anterior metatarsalgia, 538 
of acute epiphysitis at hip, 301 
anterior poliomyelitis, 443 
torticollis, 482 
of calcaneo-bursitis, 547 
of Charcot's disease, 217 
of congenital dislocation of hip joint, 
380_ 
elevation of scapula, 183 
paralysis, 461 
of coxa vara, 398 

unilateral, 397 
bilateral, 398 
of displacement of peronei tendons, 

555 
of erythromelalgia, 548 
of fracture of neck of femur, 402 
of functional affections of joints, 472 
of gluteal bursitis, 302 
of gonorrheal arthritis, 209 
of hallux rigidus, 549 
of hollow foot, 535 
of hysterical club foot, 470 

e hip, 469 
of injury of spine, 108 
of lateral curvature of spine, 141 
of malignant disease of spine, 107 
of obstetrical paralysis, 431 
of osteo-arthritis, 215 
arthropathy, 371 
of osteitis deformans, 371 
of periarthritis of shoulder, 358 
of poliomyelitis, anterior, 442 
of Pott's paraplegia, 96 
of pseudo-hypertrophic muscular pa- 
ralysis, 468 
of rhachitic spine, 109 
of rhachitis, 365 
of sacro-iliac disease, 118 
of sciatic scoliosis, 117 
of spondylitis deformans of spine, 113 
of syphilis of spine, 107 
of torticollis, 482 
of traumatic coxa vara, 402 
of tuberculous disease ankle joint, 339 
elbow joint, 351 
hip joint, 244 



Diagnosis of tuberculous knee joint, 310 
shoulder joint, 350 
of spine, 41, 50, 54 
sub-astragaloid joint, 339 
of tarsus, 341 
of typhoid spine, 110 
of weak foot, 514 
Dislocation of hip, congenital, see Hip 
Joint, Congenital Dislocation of 
373 
of shoulder, congenital, 430 
treatment of, 430 
recurrent, 432 

treatment of, 432 
operative, 433 
Displacement of peronei tendons, 555 

treatment of, 556 
"Double joints," 363 
Dupuytren's contraction, 438 
etiology of, 439 
pathology of, 439 
symptoms of, 439 
treatment of, 439 
Dystrophy, muscular, 467 

I?LBOW, congenital deformities of, 433 
J excision of, in tuberculous disease of, 
353 
joint, tuberculous disease of, 351 
Elongation ligamentum patellae, 331 
Epiphysis of head of femur, traumatic 

separation of, 404 
Epiphysitis, acute, 211 

distribution of, 211 
etiology of, 211 
prognosis, 212 
statistics of, 211 
symptoms of, 212 
treatment of, 212 
Equino-varus, hysterical, 624 
Erythromelalgia, 548 
Exercise in treatment of lateral curvature 

of spine, 151, 164 
Exostoses of foot, 555 
Etxra-articular disease of hip, 301 
of knee, 318 

FEMUR, bending of neck of, see Coxa 
Vara, 392 
depression of neck of, see Coxa Vara, 

392 
fracture of neck of, 402 
Fingers, congenital contraction of, 437 
treatment of, 437 
distortions of, 438 
drop, see Mallet Finger, 438 
jerking, see Trigger Finger, 438 
mallet, see Mallet Finger, 438 
snapping, see Trigger Finger, 438 
trigger, see Trigger Finger, 438 
webbed, 437 

etiology of, 437 
treatment of, 437 
Flat foot, see Weak Foot, 507 
Foetal rhachitis, 367 

cretinism allied to, 367 



INDEX. 



635 



Foetal rhachitis, etiology, 367 
pathology, 367 
prognosis, 367 
treatment of, 367 
Foot, contracted, 534 
deformities of, 492 
disabilities of, 492 
flat, see the Weak Foot, 507 
function of the muscles of, 502 
general description of, 492 
hollow, 534 
exostoses of, 555 
as a mechanism, 506 
movements of, 496 

plaster cast of, method of taking, 524 
relative strength of muscles of, tables 

of, 503 
splay, see Weak Foot, 507 
weak, 507 

adjuncts in treatment of, 532 
plaster strapping, 532 
Thomas treatment, 532 
anatomy of, 508 
in childhood, 519 

out and in toeing as symp- 
toms of, 519 
diagnosis of, 514 
etiology of, 511 
extreme types of, 517 
operative treatment for, 532 
pathology of, 511 
rigid, 527 

other varieties of, 531 
treatment of, 527 

forcible over-correction 

in, 527 
systematic manipula- 
tion in, 527 
statistics of, 512 
symptoms of, 513 
treatment of, 521 
attitudes in, 522 
brace in, 525 
exercises in, 523 
the shoe in, 521 
support in, 523 
varieties of, 516 
Fracture of neck of femur, 402 • 
Fragilitas ossium, 368 
Freidreich' s disease, see Hereditary Atax- 
ia, 468 

Functional affections of joints, 471 
causes of, 472 
diagnosis of, 472 
treatment of, 472 
pathogenesis of deformity, 190 
Funnel chest, 187 

GENU recurvatum, acquired, 332 
etiology of, 332 
symptoms of, 333 
treatment of, 333 
congenital, 328 

treatment of, 329 
deformities accompanied by, 328 
statistics of, 328 



Genu recurvatum, deformities accompa- 
nied by, etiology of, 329 
Genu valgum, 405-411 

accommodative attitude in, 414 
combined with general rhachitic 
distortions, 415 
with genu varum, 415 
etiology of, 406 
gait in, 414 
measurements of deformitv of, 

417 
outgrowth of deformity of, 409 
pathology, 416 
predisposition to deformity of, 

409 
secondary deformities of, 414 
statistics of, 405 
table of, 406 
time of onset of, 406 
treatment of, 417 
by braces, 419 

duration of, 420 
exercise in, 418 
expectant, 417 

manipulation in, 417 
Lorenz's operation, 423 
operative, 421 
osteoclasis in, 422 
osteotomy in, 421 

cuneiform, 422 
by plaster bandage, 421 
posture in, 418 
Thomas brace in, 420 
Wolff's, 423 
unilateral, 415 
Genu varum, 405, 423 
etiology of, 406 
measurements of deformity in, 

426 
outgrowth of deformity of, 409 
predisposition to deformity in, 

406 
statistics of, 405 * 

table of, 405 
symptoms of, 425 
time of onset of, 406 
treatment of, 426 
by braces, 426 
expectant, 426 
operative, 426 
osteotomy in, 427 
osteoclasis in, 427 
Gonorrheal arthritis, 208 
statistics of, 208 
symptoms of, 208 
treatment of, 210 
varieties of, 209 
Gonorrhoeal rheumatism, see Gonorrheal 
Arthritis, 208 
of spine, 111 

H .EM ARTHROSIS, 217 
Haemophilia, 216 
treatment, 217 
Hallux flexus, see Hallux Rigidus, 548 
rigidus, 548 



636 



INDEX. 



Hallux rigidus, etiology of, 549 

treatment of, 549 
Hallux valgus, 551 

etiology of, 552 
pathology of, 552 
symptoms of, 553 
treatment of, 553 

cuneiform osteotomy in, 554 
operative, 553 
Hallux varus, 551 

congenital, see pigeon toe, 551 
treatment of, 551 
Hammer toe, 554 

symptoms of, 554 
treatment of, 554 
Height, table of, 190 
Hemiplegia, treatment of, 463 
Hereditary ataxia, 468 

symptoms of, 469 
"High hip" of lateral curvature of 
spine, 125 
"shoulder" of lateral curvature of 
spine, 125 
Hip disease, see Tuberculous Diseases of 
Hip Joint, 221 
excision of, in tuberculous disease of 
hip joint, 290 

functional re- 
sults after, 
290, 292 
statistics of, 
289, 291 
Hip, hysterical, 469 

anterior dislocation, 380 
bilateral dislocation of, 379 

general symptoms of, 
380 
congenital dislocation of, 373 
diagnosis of, 380 
etiology, 377 
pathology, 374 
statistics, 373 

table of, 374 
symptoms, 378 
treatment of, 382 

intermediate opera- 
tion, 390 
Lorenz' s operation 

in, 386 
open operation in, 

383 
secondary osteot- 
omy in, 391 
tuberculous disease of, 221 
unilateral dislocation of, 378 
Hollow foot, 534 

etiology of, 534 
symptoms of, 535 
treatment of, 537 

operative of, 537 
Housemaid's knee, see Prepatellar Bur- 
sitis, 325 
Hutchinson's index showing relative 

depth of chest, 186 
Hysterical club foot, 470 

differential diagnosis, 471 



Hysterical equino-varus, 624 
hip, 469 

diagnosis of, 469 
differential, 470 
symptoms of, 470 
scoliosis, 471 
case of, 471 
treatment of, 471 
spine, 115 

symptoms of, 115 
treatment of, 116 

IDIOPATHIC osteopsathyrosis, see Frag- 
ilitas Ossium, 368 
Incidental lateral curvature of spine, 135 
Infantile club foot, 573 

paralysis, see Poliomyelitis Anterior, 

440 
scorbutus, 367 

pathology of, 368 

symptoms of, 368 

treatment of, 368 

In knee, see Genu Valgum, 405-411 

Injury of sacro-iliac articulation, 119 

of spine, 55, 108 
Intermediate operation, for congenital dis- 
location of hip, 390 

JERKING finger, see Trigger Finger, 
438 
Joint disease in locomotor ataxia, 218 

in affections of nervous system,. 
217, 218 
Joints, diseases of, syphilitic, 206 
acquired, 207 
hereditary, 206 

later manifestations in r 
. 207 
pseudo-paralysis in, 206 
spina ventosa in, 207 
treatment of, 208 
functional affections of, 471 
causes of, 472 
diagnosis of, 472 
treatment of, 472 
neurotic, see Joints, Functional Affec- 
tions of, 471 
Judson brace in treatment of club foot, 
600 
hip brace, 255 

KINGSLEY'S table for estimating flex- 
ion deformity, 244 
Knee, congenital contraction at, 332 

general contractions combin- 
ed with, 332 
prognosis of, 332 
treatment of, 332 
displacement of a semilunar cartilage 
in, 327 
cause of, 327 
treatment of, 327 
Campbell brace 
in, 327 
extra-articular disease of, 318 
injuries of, in childhood, 324 



INDEX. 



637 



Xnee joint, internal derangement of, 326 
loose bodies in, 326 
tuberculous disease of, 304 
snapping, 331 

treatment of, 332 
strains of, in childhood, 324 
Knight brace in treatment, lateral curva- 
ture of spine, 177 
Knock knee, see Genu Valgum, 405-411 
Kyphosis, 182 

of adolescents, 114 
postural, 183 
of rhachitis, 109, 183 
treatment of, 184 

T AMINECTOMY, 98 
Li Latent tuberculosis, 194 
Lateral curvature of spine, 120 
congenital, 135 
diagnosis of, 141 

mobility tests of, in, 142 
posture in, 141 
due to occupation, 135 
effects of deformity of, 124 
fixed deformity in, 121 
forcible correction of defor- 
mity of, 177 
combined with 
fixation, 178 
habitual deformity in, 121 
hereditary influence in, 137 
the "high hip" of, 125 
"shoulder" of, 125 
incidental, 135 
lateral deviation in, 124 
occupation as a factor in, 137 
pathology of, 126 
prevention of deformity of, 

146 
prognosis of, 143 
record of case, 142 
rhachitic, 135 
rotation in, 123 
secondary to deformity else- 
where, 133 
to disease within tho- 
racic walls, 134 
to paralysis, 133 
statistics of, 130 
age, 131 
frequencv, 130 
sex, 130 
symptoms of, 141 
treatment of, 147 

by braces, 148, 176 
corsets in, 177 
duration of, 180 
exercises in, 151, 164 
general, 180 
high shoe in, 180 
Knight brace in, 177 
self -suspension in, 175 
Teschner's exercises in, 

151 
Volkmann seat in, 180 
varieties of deformity in, 139 



" Late rickets," 366 

Ligamentum patella?, elongation of, 331 
etiology, 331 
symptoms, 331 
treatment, 331 
Linear osteotomy in treatment of coxa 

vara, 400 
Lipoma, arborescens tuberculosum, 201 
Locomotor ataxia, joint disease in, 218 
Lordosis, 184 

treatment of, 185 
Lorenz operation, for congenital disloca- 
tion of hip, 386 
for genu valgum, 423 
reclination gypsbettes in treatment, 
Pott's disease, 60 
Lovett's table for estimating lateral dis- 
tortion in tuberculous disease, hip joint, 
242 
Lumbar Pott's disease in infancy, peculi- 
arities of, 44 

MALIGNANT disease of spine, 107 
diagnosis of, 107 
Malleotomy in treatment of club foot, 591 
Mallet finger, 438 
Metatarsalgia, anterior, 538 
etiology of, 538 

influence of shoe in causing dis- 
ability and pain in, 541 
pathology of, 538 
treatment of, 542 
brace for, 543 
support in, 543 
Metzger-Goldthwait apparatus, 105 
Mollitis ossium, see Osteomalacia, 369 
Morbus coxa?, see Tuberculous Disease of 

Hip Joint, 221 
Morton' s neuralgia, see Metatarsalgia An- 
terior, 538 
Muscles of leg, relative strength of, 628 

pectoral, defective formation of, 188 
Muscular atrophy, progressive,* 466 

dystrophy, 467 
Myelopathic paralysis, 466 

NECK, deformities of, in anterior polio- 
myelitis, 447, see torticollis, 474 
Nervous system affections of, joint disease 
in, 217, 218 
diseases of, 440 
Neuritis, 469 

treatment of, 469 
Neurotic joints, see Joints, Functional Af- 
fections of, 471 
spine, 114 

symptoms of, 115 
treatment of, 115 
Non-deforming club foot, see Hollow 

Foot, 534 
Non-tuberculous affections of the ankle 
joint, 342 
of the hip joint, 300 
of the knee joint, 324 
of the spine, 107 
disease of joints, 206 



638 



INDEX. 



OBSTETKICAL paralysis, 431 
treatment of, 431 
Ocular torticollis, 491 
(Edema of foot, congenital, 608 
Open operation, for congenital dislocation 

of hip, 383 
Osteitis deformans, 370 

deformities of, 370 
of spine, 114 
Osteo-arthritis, 212 

atrophic form, 214 
etiology of, 213 
of knee joint, 325 

symptoms of, 325 
treatment of, 325 
localized form, 214 
multiple form, 213 

statistics of, 214 
pathology, 212 

of spine, see spondylitis defor- 
mans, 111 
case of, 113 
symptoms of, 215 
treatment of, 215 

by apparatus, 216 
by forcible manipulation, 
216 
varieties of, 213 
Osteo-arthropathy, 370 

treatment of, 371 
Osteoclasis in treatment of genu valgum, 
422 
in treatment of genu varum, 427 
in treatment of talipes, 596 
Osteomalacia, 369 

in childhood, 369 
cases of, 369 
treatment of„ 370 
deformities of, 369 
symptoms of, 369 
Osteomyelitis, infectious localized, 212 
of spine, 108 

symptoms of, 108 
treatment of, 108 
Osteotomy for correction deformity of 
tuberculous disease hip joint, 293 
cuneiform in treatment of club foot, 
599 
in treatment of coxa vara, 401 
in treatment of hallux valgus, 
554 
linear in treatment of coxa vara, 

400 
secondary in treatment, anterior polio- 
myelitis, of club foot, 600 
in treatment of, 457 
of club foot, 598 
of genu valgum, 421 
varum, 427 
Over-lapping toes, 555 

PAGET' S disease, 370 
see osteitis deformans of spine, 114 
Painful great toe, see Hallux Rigidus, 548 
joint in older subjects, 550 
heel, 547 



Pain in lower part of back, 116 

treatment of, 116 
Paralysis, acquired, 459, 462 
deformities in, 462 
disability of, 463 
loss of growth in, 463 
Sach's classification of causes and 
effects of, 459 
of anterior muscles of leg in anterior 
poliomyelitis, 450, see Talipes 
Poliomyelitis, 444 
of arm in anterior poliomyelitis, 455 
cerebral, in childhood, 459 
congenital, 459, 461 

deformities in, 462 
electrical test for, in anterior polio- 
myelitis, 445 
infantile, see Poliomyelitis, Anterior, 

440 
muscles of hip in anterior poliomye- 
litis, 454 
myelopathic, 466 

Aran-Duchenne type of, 466 
Charcot-Marie-Tooth type of, 466 
myopathic, 467 
obstetrical, 431 

treatment of, 431 
of posterior muscles of leg in anterior 

poliomyelitis, 451 
in Pott' s disease, 93 
pseudo-hypertrophic muscular, 468 
diagnosis of, 468 
treatment of, 468 
spastic, 459 

etiology of, 459 
pathology of, 459 
prognosis of, 466 
statistics of distribution of, 459 
statistics of mental impairment in, 461 
symptoms of, 460 
mental, 460 
motor, 460 
of thigh muscles, anterior poliomye- 
litis, 451 
Paralytic scoliosis in anterior poliomye- 
litis, 454 
torticollis, 491 
Paraplegia, treatment of, 93, 464 
Patella, congenital displacement of, 329 
rudimentary or absent, 329 

treatment of, 329 
slipping, 330 
etiology, 330 
symptoms, 330 
treatment, 330 
operative, 330 
Pathogenesis of deformity, functional, 190 
Pectoral muscles, defective formation of, 

188 
Pectus carinatum, see Pigeon Chest, 186 

excavatum, see Funnel Chest, 187 
Pelvic abscess in lumbar Pott's disease, 40 
Periarthritis of the shoulder, 358 
symptoms of, 358 
treatment of, 358 
Peronei tendons, displacement of, 555 



INDEX. 



639 



Pes planus, 518 

Phalanges, congenital displacement of, 

438 
Phelps' bed in treatment Pott's disease, 
60 
hip splint, 278 

operation for immediate correction of 
deformity of club foot, 596 
Pigeon breast, 364 
chest, 186 

treatment of, 187 
toe, 551 
Plantalgia, see Plantar Neuralgia, 548 
Plantar fascia, division of, in treatment 
of club foot, 593 
of hollow foot, 537 
Plantar neuralgia, 548 

treatment of, 548 
Plaster bandage in treatment tuberculous 
disease hip joint, 265, 266 
cast of foot, method of taking, 524 
corset, 76 
jacket, application of, 70 

in recumbency, 74 
Poliomyelitis, anterior, acute, 440 

causes of deformity of, 445 
deformities of lower extrem- 
ity in, 450 
of neck in, 447 
secondary in, 449 
of trunk in, 448 
of upper extremity in, 
447 
diagnosis of, 443 

differential, 443, 444 
etiology of, 441 
pathology of, 440 
prognosis of, 444 
retardation of groAvth in, 

449 
statistics of, 441 

tables of, 441, 442 
symptoms of, 442 
treatment of, 450 

mechanical, principles 

of, 450 

prevention of deformitv 

m in, 450 

arthrodesis in, 456 

osteotomy in, 457 

paralysis in, 444 

of anterior muscles of leg in, 

450 
of arm in, 455 
electrical test for, 445 
of posterior muscles of leg, 

451 
of thigh muscles, 451, 454 
paralytic scoliosis in, 454 

torticollis in, 490 
reduction of deformity of, 455 

by braces, 456 
tendon transplantation in, 456 
treatment of, operative, 455, 457 
Popliteal region, bursse and cysts in, 326 
Posterior torticollis, 491 



Pott's disease, see Tuberculous Disease of 
Spine, 17 
complications of, 87 
abscess, 87 

in different regions, 88 
treatment of, 89 
paralysis in, 93 

duration of, 95 

prognosis, 95 
statistics of frequency 
of, 93 
liability to, in dif- 
ferent regions, 94 
time of onset, 95 
symptoms of, 95 
treatment of, 97 
duration of, 99 
operative, 98 
forcible correction deformity of, 
101 
statistics of results 

of, 102 
selection of cases 
for, 102 
gradual correction of deformity 
of, 104 
Metzger-Goldthwait 
apparatus for, 105 
local paralysis in, 98 
recurrence of, 100 
secondary deformities, 100 
statistics of, 21 
age, 22 
frequency, 21 
sex, 22 
situation, 22 
Pott's fracture, 624 
Pott's paraplegia, 95 

symptoms of, 95 
Pretibial bursa, enlargement of superficial, 

326 
Prepatellar bursitis, 325 

treatment of, 325 » 

Pretibial bursitis, 326 

symptoms of, 326 
treatment of, 326 
Progressive muscular atrophy, 466 
Pseudo-hvpertrophic muscular paralysis, 
468 
diagnosis of, 468 
treatment of, 468 
Pseudo-paralysis in rhachitis, 34 
in syphilitic disease, 206 
Psychical torticollis, 491 
Puerperal arthritis, 210 

RETENTION brace in treatment of club 
foot, 581 
Retro-calcaneo bursitis, see achillo-bur- 

sitis, 544 
Ehachitic distortions, general, 429 
kyphosis, 109 

lateral curvature of spine, 135 
rosary, 363 

spine, 45, 109, 110, 183, 364 
treatment of, 110 



640 



INDEX. 



Khachitis, 361 

deformities of, 362 

caput quadratum, 363 
' ' craniotabes, ' ' 363 
" double joints," 363 
pigeon breast, 364 
"rhachitic rosary," 363 
attitude, 364 
pseudo-paralysis, 364 
spine, 45, 109, 110, 183, 364 
etiology of, 361 
foetal, 367 

cretinism allied to, 367 
etiology, 367 
pathology, 367 
prognosis, 367 
treatment of, 367 
kyphosis of, 109, 183 
pathology of, 361 
prognosis of, 365 
symptoms of, 362 
treatment of, 365 

Bradford frame in, 366 
prevention of deformity in, 366 
Rheumatism of spine, 56, see also Spondy- 
litis Deformans, 111 
Rheumatoid arthritis, see Osteo-arthritis, 
212 
of knee joint, 325 
of spine, chronic, 113 
Ribs, absence of, 188 
Rice bodies in tuberculous joint disease, 

201 
Rickets, see Rhachitis, 361 
Rigid flat foot, see Rigid Weak Foot, 527 
weak foot, 527 

treatment of, 527 

forcible over-correction 

in, 527 
plaster strapping in, 532 
systematic manipulation 

in, 527 
Thomas, 532 
Rotary lateral curvature, see lateral curva- 
ture of the spine, 120 
Rudimentary patella, 329 

SACRO-ILTAC articulation, injury of, 
119 
disease of, 117 

abscess in, 119 
diagnosis of, 118 
prognosis of, 118 
symptoms of, 117 
treatment of, 118 

Thomas hip brace in, 
119 
Scapula, congenital elevation of, 185 
etiology of, 185 
treatment of, 186 
Sciatica, deformity secondary to, 117, 119 
Sciatic scoliosis, see Sciatica, Deformity 

Secondary to, 117 
Scoliosis, see Lateral Curvature of Spine, 
120 



Scoliosis, hysterical, 471 
case of, 471 
treatment of, 471 
paralytic in anterior poliomyelitis, 454 
total, 122 
Scorbutus, hemorrhage in, 217 
infantile, 367 

symptoms of, 368 
treatment of, 368 
Scurvy, see Scorbutus, Infantile, 367 

rickets, see Scorbutus, Infantile, 367 
Secondary, hypertrophic osteo-arthrop- 

athy, 370 
Shoes, 556 

Shoulder, chronic bursitis at, 359 
congenital dislocation of, 430 

treatment of, 430 
joint, tuberculous disease of, 348 
periarthritis of, 358 
symptoms of, 358 
treatment of, 358 
recurrent dislocation of, 432 
treatment of, 432 
operative, 433 
Sinuses in tuberculous disease hip joint, 

treatment of, 289 
Slipping patella, 330 
Snapping finger, see Trigger Finger, 438 

knee, 331 
Spasmodic torticollis, 486 
Spastic paralysis, 459 

torticollis, 480 
Spina bifida and talipes, 608 
ventosa, 356 

statistics of, 356 

in syphilitic disease, 207 

treatment, 357 

operative, 357 
Spine, actinomycosis of, 108 

antero-posterior deformities of, 182 
kyphosis, 183 
postural, 183 
of rhachitis, 109, 
183, 364 
lordosis, 184 

treatment of, 185 
treatment of, 184 
arthritis of, 111 

treatment of, 111 
changes in antero-posterior contour 

of, 125 
contour and flexibility of normal, 29 

variations in, 181 
divisions of, 30 
injury of, 55, 108 
gonorrheal rheumatism of, 111 
hysterical, 115 

symptoms of, 115 
treatment of, 116 
landmarks of, 32 
lateral curvature of, 120 
congenital, 135 
diagnosis, 141 

mobility tests of, in, 

142 
posture in, 141 



INDEX. 



641 



Spine, lateral posture in, due to occupa- 
tion, 135, 137 
effects of deformity of, 124 
fixed deformity in, 121 
forcible correction of defor- 
mity in, 177 
combined with 
fixation, 178 
habitual deformity in, 121 
hereditary influence in, 137 
the "high hip" of, 125 
"shoulder" of, 125 
incidental, 135 
lateral deviation in, 124 
pathology of, 126 
prevention of deformity in, 

146 
prognosis of, 143 
record of case, 142 
rhachitic, 135 
rotation in, 123 
secondary to deformity else- 
where, 133 
to disease within thor- 
acic walls, 134 
to paralysis, 133 
statistics, 130 
age, 131 
frequency, 130 
sex, 130 
symptoms of, 141 
treatment of, 147 

by braces, 148, 176 
corsets in, 177 
duration of, 180 
exercise in, 151, 164 
Teschner's, 151 
general, 180 
Knight brace in, 177 
high shoe in, 180 
self-suspension in, 175 
Volkmann seat in, 180 
varieties of deformity in, 139 
malignant disease of, 107 
diagnosis of, 107 
neurotic, 114 

symptoms of, 115 
treatment of, 115 
osteitis deformans of, 114 
osteo-arthritis of, see Spondylitis De- 
formans, 111 
case of, 113 
osteomyelitis of, 108 
symptoms of, 108 
treatment of, 108 
physiological movements of, 120 
rhachitic, 45, 109, 110, 183, 364 

treatment of, 110 
rheumatism of, see Spondylitis De- 
formans, 111 
rheumatoid arthritis of, case of, 113 
syphilis of, 107 

diagnosis of, 107 
traumatic spondylitis, 109 
tuberculous disease of, 17 
typhoid, the, 110 
41 



Spine, typhoid, the, treatment of, 110 

variations in contour of, 181 
Splay foot, see Weak Foot, 507 
Spondylolisthesis, 116 
Spondyloze Khizomelique, see Spondy- 
litis Deformans, 111 
Spondylitis deformans, 111 
case of, 113 
pathology of, 111 
symptoms of, 112 
treatment of, 114 
traumatic, 109 
Spontaneous amputations, congenital, 

608 
Sprain of the ankle, 342 
chronic, 344 
of wrist, 359 

chronic, 359 
Sprengel's deformity, see congenital ele- 
vation of scapula, 185 
Statistics of anterior poliomyelitis, 441 
of club hand, 435 

of congenital dislocation at hip joint, 
373 
talipes calcaneus, 604 
equinus, 604 
valgus, 605 
calcaneo-valgus, 605 
equino-valgus, 605 

associated with congenital 

absence fibula, 606 
varus associated with con- 
genital absence tibia, 
607 
of coxa vara, 394 
genu valgum, 405 

varum, 405 
lateral curvature of spine, 130 
age, 131 
frequency, 130 
sex, 130 
varieties, 140 
of osteo-arthritis, 214 
of Pott' s disease, 21 
age, 22 
frequency, 21 
sex, 22 

situation of, 22 
of results of tuberculous joint dis- 
ease, 203, 295, 298, 322, 323, 341, 
349, 354 
of spina ventosa, 356 
of synovial disease of joints, 201 
of talipes, 566 

foot affected, 567 
relative frequency of different 
forms, acquired, 568 

congenital, 567 
comparative frequency of differ- 
ent forms, congenital and ac- 
quired, 568 
sex, 567 
of torticollis, 474 
acquired, 481 

table of, 481 
spasmodic, 487 



042 



INDEX. 



Statistics of tuberculous disease of elbow 
joint, 351, 354 
hip joint, 224 

age, 197, 198, 225 
at incipiency 
table of, 22 
deformity in, 248 
excision, 289, 291 
functional results, 

259, 297, 298 
mortality, 295 
retardation of 
growth, tables of, 
238, 239 
sex, 197, 225 
side affected, 197, 
225 
of shoulder joint, 348, 349 
of wrist joint, 354 
of weak foot, 512 
Sterno-mastoid muscle, hematoma of, 477 
Stiffness of vertebral column, see Spondy- 
litis Deformans, 111 
Strain of the tendo Achillis, 547 
Symptoms of abscess in Pott's disease, 87 
of achillo-bursitis, 545 
posterior, 547 
of actinomycosis of spine, 108 
of acquired genu recur vat um, 333 
talipes calcaneus, 618 
equinus, 612 
of acromegalia, 372 
of acute anterior poliomyelitis, 442 

torticollis, 481 
of anchylosis, 218 
of anterior bow leg, 429 

metatarsalgia, 538 
of arthritis deformans at hip, 302 
of bilateral dislocation at hip joint, 

380 
of bow leg, 423 
of bursa? at hip, 302 
at knee, 326 
at shoulder, 359 
of calcaneo-bursitis, 547 
of Charcot's disease, 217 
of club hand, 434 
of congenital club foot, 572 

dislocation of hip joint, 378 
of shoulder joint, 430 
of coxa vara, 394 
of cubitus valgus, 433 

varus, 433 
of displacement of peronei tendons, 

555 
of Dupuytren's contraction, 439 
of elevation of scapula, 185 
of elongation of ligamentum patellae, 

331 
of epiphysitis, 212 

at hip joint, 301 
of erythromelalgia, 548 
of extra-articular disease at hip joint, 

301 
of flat chest, 186 
of foetal rhachitis, 367 



Symptoms of funnel chest, 187 

of genu recurvatum, acquired, 332 
congenital, 328 

varum, 425 
of gonorrhceal arthritis, 208 

of spine, 110 
of hsemarthrosis, 217 
of haemophilia, 210 
of hallux rigidus, 548 

valgus, 553 
of hammer toe, 554 
of hereditary ataxia, 469 
of hollow foot, 535 
of hysterical club foot, 470 

hip, 470 

scoliosis, 471 

spine, 115 
of infantile scorbutus, 368 
of infectious arthritis, 210 
of injury of hip, 300 

of knee, 324 

of spine, 108 
of internal derangement of knee, 327 
of knock knee, 412 
of kyphosis, 182 
of late rickets, 366 
of lateral curvature of spine, 141 
of lordosis, 184 

of malignant disease of spine, '107 
of mallet finger, 438 
of neuritis, 469 
of neurotic joints, 471 

spine, 115 
of obstetrical paralysis, 431 
of osteo-arthritis, 215 

of knee joint, 325 
of osteomalacia, 369 
of osteomyelitis of spine, 108 
of osteitis deformans, 114, 370 
of paralysis, 442, 460 

in Pott' s disease, 95 
of periarthritis of shoulder, 358 
of pigeon chest, 186 
of plantar neuralgia, 548 
of Pott' s paraplegia, 95 
of prepatellar bursitis, 325 
of pretibial bursitis, 326 
of recurrent dislocation of shoulder, 

432 
of rhachitis, 362 
of sacro-iliac disease, 117 
of sciatic scoliosis, 117 
of scorbutus, 217, 367 
of slipping patella, 330 
of snapping knee, 331 
of spastic paralysis, 459 
of spina ventosa, 356 
of spondylitis deformans, 112 
of spondylolisthesis, 116 
of sprain of ankle, 342 
of syphilitic disease of joints, 206 
of syphilis of spine, 107 
of talipes acquired, 609 

congenital, 560 
of teno-synovitis, 346 
of torticollis, acquired, 479 



INDEX. 



643 



Symptoms of torticollis, congenital, 475 
spasmodic, 486 
spastic, 480 
of trigger finger, 438 
of tuberculous disease of ankle joint, 
336 
of elbow joint, 351 
of hip joint, 225 
of knee joint, 306 
of shoulder joint, 349 
of spine, 24 
of tarsus, 341 
of wrist joint, 355 
of unilateral coxa vara, 396 
of weak foot, 513 
of webbed fingers, 437 
Synovial disease of joints, statistics of, 201 
in tuberculous disease of knee 
joint, 318 
treatment of, 
318 
c a r b o lie 
acid in, 
318 
chloride 
o f zinc 
in, 318 
i o d of orm 
injection 
in, 319 
venous 
stasis in, 
319 
Synovitis, 324 
chronic, 324 

treatment of, 324 

aspiration in, 325 
braces in, 325 
treatment of, 324 

plaster strapping in, 324 
Syphilitic disease of joints, 206 
acquired, 207 
hereditary, 206 

later manifestations in, 
207 
pseudo-paralysis in, 206 
spina ventosa in, 207 
treatment of, 208 
of spine, 107 

diagnosis of, 107 

TABLE of age at incipiency tuberculous 
disease ankle joint, 335 
elbow joint, 351 
hip joint, 225 
knee joint, 306 
of shoulder joint, 

349 
of spine, 22 
of wrist joint, 355 
of patients treated at Tubingen for 
tuberculous disease ankle joint, 
336 
Kingsley's, 244 
Lovett's, 242 
of statistics acquired torticollis, 481 



Table of anterior poliomyelitis, 441, 442 
of congenital dislocation of hip 

joint, 374 
of coxa vara, 395 
of genu valgum, 406 

varum, 405 
of lateral curvature of spine, 130 
of normal development, 190 
of talipes, 567, 568 
Talipes, 560 

acquired, 609 

etiology of, 609 

development of deformity in, 609 
differential diagnosis in, 610 
statistics of, 566 

foot affected, 567 

relative frequency, different 

forms, 568 
sex, 567 
arcuatus, see Hollow Foot, 534 
calcaneo-valgus, 622 

statistics of, 605 
treatment of, 622 
-varus, 622 

statistics of, 605 
treatment of, 622 
calcaneus, acquired, 616 

astragalectomy for, 620 
development of deformity of, 

617 
symptoms of, 618 
treatment of, 618 

operative, 619 
Willett's operation for, 619 
congenital, 604 

statistics of, 604 
treatment of, 604 
cavus, see Hollow Foot, 534 

statistics of, 605 
congenital, 562 

etiology of, 563 
statistics of, 566 

foot affected, 567 

relative frequency different 

forms, 567 
sex, 567 
equino-cavus, statistics of, 605 
valgus, acquired, 623 

associated with congenital 
absence of 
fibula, 606 
etiology of, 607 
statistics of, 606 
treatment of, 
607 
statistics of, 605 
treatment of, 623 
varus, 569 

acquired, 623 
treatment of, 623 

cuneiform osteotomy in, 
623 
equinus, acquired, 611 
etiology of, 612 
immediate correction of de- 
formity of, 614 



644 



INDEX. 



Talipes, equinus, Thomas wrench for, 614 
effect of, 615 
prognosis of, 613 
symptoms of, 612 
treatment of, 613 

Shaffer extension brace 
in, 614 
congenital, 604 

statistics of, 604 
etiology of, 562 

paralytic, tendon transplantation for 
the relief of, 624 
other methods, 625 
Parish's operation, 
625 
plantaris, see Hollow Foot, 534 
Talipes and spina bifida, 608 

valgo-cavus, statistics of, 605 
valgus, congenital, 605 

statistics of, 605 
varieties of, 560 

varus associated congenital absence 
tibia, 607 

prognosis of, 

607 . 
statistics of, 607 

treatment of, 
607 
congenital, 603 
Tarsus, tuberculous disease of, 341 
Taylor back brace, 63 

foot brace, 581, 582 
Taylor hip braces, 256, 279, 281 
Tendo Achillis, division of, in treatment 
of club foot, 592 
strain of, 547 
Tendon splicing, 629 

transplantation for relief of paralytic 
talipes, 624 
Nicoladoni's opera- 
tion, 624 
Parish's operation, 

625 
other methods of, 
625 
in treatment of anterior poliomy- 
elitis, 456, see Talipes 
Teno-synovitis, 345 

at ankle, 346 
symptoms of, 346 
treatment of, 347 
tuberculous, 347 
at wrist, 360 
Tenotomy, subcutaneous, in treatment of 

talipes, 591 
Teschner' s exercises in treatment of lateral 

curvature of spine, 151 
Thomas brace, in treatment of genu val- 
gum, 420 
tuberculous disease ankle 
joint, 340 
collar, 79 
hip brace in treatment sacro-iliac 

disease, 119 
knee brace in treatment of tuber- 
culous disease of knee joint, 314 



Thomas knee brace, description of, 315 
method forcible correction of deform- 
ity of club foot, 595 
treatment tuberculous disease, hip 

joint, 260 
hip splint, 261 

wrench in treatment of talipes, 595, 
614 
Tibialis anticus, division of, in treatment 
of club foot, 593 
posticus, division of, in treatment of 
club foot, 593 
Toes, over-lapping, 555 
Torticollis, 474 
acquired, 479 

statistics of, 481 
table of, 481 
varieties of, 479 
acute, diagnosis of, 482 
differential, 483 
etiology of, 479 
spastic, 480 

causes of, 480 
symptoms of, 481 
congenital, 475 

deformity of, 475 
etiology of, 477 

hsematoma of stern Q-mastoid mus- 
cle in, 477 
pathology of, 478 
secondary distortions of, 476 
following diphtheritic paralysis, 491 
ocular, 491 
paralytic, 490 
posterior, 491 
psychical, 491 
rhachitic, 491 
spasmodic, 486 

etiology of, 487 
pathology of, 487 
prognosis of, 487 
statistics of, 487 
treatment of, 487 

operation in, 488 
statistics of, 474 
treatment of, 483 

correction of deformity in, 484 

by subcutaneous tenot- 
omy, 484 
open operation, 484 
Traction hip brace, 251 

application of, 254 
Traumatic coxa vara, 402 

diagnosis of, 402 
treatment of, 402 
separation of epiphysis of head of 

femur, 404 
spondylitis, 109 
valgus, 624 
Treatment of abscess in Pott's disease, f 89 
in tuberculous disease of hip 
joint, 287 
of knee joint, 318 
of achillo-bursitis, 546 
posterior, 547 
of actinomycosis of spine, 108 



INDEX. 



645 



Treatment of acquired genu recurvatum, 
333 
of luxation of clavicle. 188 
of talipes calcaneus, 618 
of equino-valgus, 623 

-varus, 623 
of equinus, 613 
of valgus, 624 
of varus, 624 
of acute anterior poliomyelitis, 450 

of torticollis, 483 
of anchylosis, 219 
of anterior bow leg, 429 

of metatarsalgia, 542 
of arthritis following infectious dis- 
ease, 211 
of spine, 111 
deformans at hip, 303 
of bilateral dislocation of hip joint, 

382 
of bow leg, 426 
of bursa? at hip, 302 
of knee , 326 
of shoulder, 359 
of calcaneo-bursitis, 547 
of Charcot's disease, 218 
of club hand, 436 

of congenital absence of fibula, 607 
of radius, 436 
of ribs, 188 
of tibia, 607 
calcaneus, 604 
club foot, 572 
contraction of fingers, 437 

at knee, 332 
defect of pectoral muscles, 188 
deficiencies of the foot, 608 
dislocation of hip joint, 382 

of shoulder, 430 
elevation of scapula, 186 
torticollis. 483 
of coxa vara, 399 

unilateral, 400 
bilateral, 401 
of displacement of peronei tendons, 

556 
of double tuberculous disease of hip 

joints, 284 
of Dupuytren's contraction, 439 
of elongation of ligamentum patellae, 

331 
of epiphysitis, 212, 300 

at hip, 301 
of extra-articular disease at hip joint, 

301 
of flat chest, 186 
of foetal rhachitis, 367 
of funnel chest, 188 
of functional affections of joints, 472 
of genu recurvatum, acquired, 333 
congenital, 329 
valgum, 417 
varum, 426 
of gonorrhoeal arthritis, 210 

of spine, 110 
of haemarthrosis, 217 



Treatment of haemophilia, 217 
of hallux rigidus, 549 

valgus, 553 

varus, 551 
of hammer toe, 554 
of hemiplegia, 463 
of hereditary ataxia, 469 
of hollow foot, 535 
of hysterical club foot, 471 

hip, 471 

scoliosis, 471 

spine, 116 
of infantile scorbutus, 368 
of infectious arthritis, 210 
of knee joint, 325 
of injurv of hip, 300 

knee, 324 

spine, 109 
of internal derangement of knee, 327 
of knock knee, 412 
of kyphosis, 184 

of lateral curvature of the spine, 147 
of lordosis, 185 

of malignant disease of spine, 108 
of mallet finger, 438 
of neuritis, 469 
of neurotic joints, 471 
of neurotic spine, 115 
of obstetrical paralysis, 431 
of osteo-arthritis, 215 

at hip joint, 302 
at knee joint, 325 

-arthropathy, 371 
of osteomalacia, 369 

in childhood, 370 
of osteomyelitis of spine, 108 
of osteitis deformans, 370 
of pain in lower part of back, 116 
of paralysis, 450, 464, 468 

in tuberculous disease of spine, 97 
of paraplegia, 97, 464 
of periarthritis of shoulder, 358 
of pigeon chest, 187 
of plantar neuralgia, 548 
of prepatellar bursitis, 325 
of pretibial bursitis, 326 
of pseudo-hypertrophic muscular pa- 
ralysis, 468 
of recurrent dislocation of shoulder, 

432 
of rhachitis, 365 

foetal, 367 
of rhachitic distortions, 365 
of rudimentary or absent patella, 329 
of sacro-iliac disease, 118 
of sciatic scoliosis, 117 
of scorbutus, 217, 368 
of sinuses in tuberculous disease of 

hip joint, 289 
of slipping patella, 330 
of snapping knee, 332 
of spasmodic torticollis, 487 
of spastic paralysis, 463 

torticollis, 486 
of spina ventosa, 357 
of spondylitis deformans, 114 



646 



IX I.) EX. 



Treatment of spondylolisthesis, 117 
of sprain of ankle, 343 
chronic, 345 
of wrist, 359 

chronic, 359 
of subluxation of wrist, 434 
of synovial tuberculous disease of 

knee joint, 318 
of synovitis, 324 
chronic, 324 
of syphilitic disease of joints, acquir- 
ed, 208 
hereditary, 208 
of syphilis of spine, 107 
of talipes acquired, 613 
calcaneus, 618 
calcaneo-valgus, 622 

-varus, 622 
cavus, see Hollow Foot, 535 
equinus, 613 
equino-valgus, 624 

-varus, 624 
planus, see Weak Foot, 521 
valgus, 624 
varus, 624 
congenital, 573 
calcaneus, 604 
calcaneo-valgus, 605 

-varus, 605 
cavus, 605 
equinus, 604 
equino-valgus, 605 

-varus, 605 
valgus, 605 
varus, 604 
of teno-svnovitis, 347 
of ankle, 347 
of wrist, 360 _ 
of torticollis acquired, 483 
congenital, 483 
chronic, 483 
spasmodic, 487 
spastic, 486 
of traumatic coxa vara, 402 

separation of the epiphysis of 
head of femur, 403 
of trigger finger, 438 
of tuberculous disease of ankle joint, 
339 
of elbow joint, 352 
of hip joint, 249 
of knee joint, 311 
of shoulder joint, 350 
of spine, 58 
of tarsus, 342 
of wrist joint, 355 
joint disease, 204 
of typhoid spine, 110 
of weak foot, 521 

rigid, 527 
of webbed fingers, 437 
Trigger finger, 438 

etiology of, 438 
treatment of, 438 
Trunk, deformities of, in anterior polio- 
myelitis, 448 



Tuberculosis, arborescent synovial, 201 

latent, 194 
Tuberculous arthritis, acute, 212 
disease of ankle joint, 334 

abscess in, 334 

situation of disease, 
335 
deformity of, 336 
etiology of, 335 

statistics of, 335 
age at incipi- 
ency, table of, 
335 
age of patients 
treated at 
T u b i n g en, 
table of, 336 
frequency of, 334 

statistics of, 334 
pathology of, 334 
physical examination in, 

337 
prognosis in, 341 
statistics, final results, 

341 
symptoms of, 336 
treatment of, 339 
operative, 340 
reduction of deform- 
ity in, 339 
by plaster bandage, 

339 
Th omas brace in, 340 
removal of astrag- 
alus in, 340 
description of 
operation, 340 
bones and joints, 194 
of elbow joint, 351 

excision of elbow in, 353 
description ^of 
operation, 354 
final results of, 
354 
pathology of, 351 
prognosis of, 353 
statistics, age at incip- 
iencv, table of, 
351 
situation of, 351 
symptoms of, 351 
treatment of, 352 
operative, 353 
reduction of defor- 
mity in, 352 
Thomas method 
of, 352 
general dissemination of, 203 

by operation, 203 
of hip joint, 221 

abscess in, 285 

frequency of, 285 
significance of, 286 
treatment of, 287 
by aspiration , 
288 



INDEX. 



647 



Tuberculous disease of hip joint, treat- 
ment by incis- 
ion, 288 ^ 
b v injection, 
*288 
actual lengthening in, 
238 
shortening in, 236 
causes of, 236 
in the adult, 285 
amputation in, 292 
atrophy in, 234 

Brackett's observa- 
tions on, 235 
causes of, 234 
theory of Saborin, 

234 
theory of Vulpian 
and Charcot, 234 
changes in contour of 

the hip, 234 
in combination, 284 
deformities incidental 

to, 299 
diagnosis of, 244 

Rontgen ray in, 
247 
distortions of, 228 

apparent lengthen- 
ing in, 229 
shortening in, 
230 
explanation of, 229 
mechanics of, 232 
double, 283 

treatment of, 284 
examination in, method 
of, 240 
physical, 240 
excision of hip in, 290 
functional r e- 
sults after, 
290 5< 292 
statistics o f, 
289, 291 
exploratory operations 

in, 289 
etiology of, 224 
general symptoms of, 
240 
debility, 240 
fever, 240 
history of, 240 
in infancy, 285 
local signs of, 244 
measurements in, 241 
method of estimating 
degree of dis- 
tortion in, 
242 
Kingsley's ta- 
ble, 244 
Lovett's table, 
242 
of recording case in, 
247 



Tuberculous disease of hip joint, other 
deformities incidental 

to, 299 
pathology of, 221 

changes in the 

joint, 223 _ 
situation of disease, 
223 
prognosis in, 294 

functional results of, 
297 
statistics of, 
297, 298 
mortality, 295 

statistics of, 295 
progression of symp- 
toms in, 249 
reduction of deformitv 
of, 256, 258 
by osteotomv, 

293 
by plaster ban- 
dage, 265 
bv Thomas 

splint, 263 
by traction 

brace, 256 
by weight and 
pulley, 268 
relative frequency of, 

196, 197, 224 
retardation of growth in, 
238 
tables of, 23S, 
239 
sinuses in, treatment of, 

289 
statistics of, 224 

age, 197, 198, 225 
age at incipiencv, 

table of, 225 
of deformity in, 248 
sex, 197, 225 
side affected, 197, 
225 
symptoms of, 225 
limp, 226 
night cry, 226 
pain, 226 
reflex muscular 

spasm, 227 

stiffness, 227 

treatment of, 249 

Bradford frame in, 

271 
chair for, 278 
during convales- 
cence, 280 
splints for, 280, 
281 
fixation in, 272 
"high shoe" in, 254 
Judson's brace in, 

255 
lateral traction in, 
271 



648 



INDEX. 






Tuberculous disease of hip joint, treat- 
ment, long hip 
brace in, 276, 277 
mechanical princi- 
ples of, 251 
perineal bands in, 

254 
Phelps' hip brace 

in, 278 
plaster spica band- 
age in, 266 
application of, 
266 
reduction of de- 
formity in, 256, 
263, 268, 293 
"stilting" in, 273 
Taylor' s braces for, 

276, 279 
Thomas' splint in, 
261 
description of, 

261 
iuodifi cation 
m of, 264 
traction brace, va- 
rieties of, 252 
relative effici- 
ency of, 257 
traction bra cein ,251 
traction, splinting, 
stilting, combin- 
ed in, 273 
traction straps in, 253 
of joints, synovial disease, 201 
statistics of, 201 
of knee joint, 304 

abscess in, 318 

statistics of, 318 
treatment of, 318 
bv aspiration, 

*318 
by incision, 318 
actual lengthening in, 
310 
shortening in, 310 
amputation in, 321 
arthrectomy in, 319 
advantages of, 319 
results of, 319 

statistics of, 319 
table of short- 
ening in, 320 
deformity in, 322 

statistics of, 322 
diagnosis of, 310 

differential, 310,311 
etiology of, 305 
excision in, 320 

description of oper- 
ation, 320 
mechanical support 

after, 321 
results of, 321 
selection of cases 
for, 320 



Tuberculous disease of knee joint, func- 
tional results of, 322 
statistics of, 322 
general conclusions on, 

323 
mortality of, 322, 323 
operations for relief, fi- 
nal deformity of, 321 
pathology of, 304 
primary distortions in, 

307 
prognosis of, 321 

statistics of, 321 
retardation of growth 
in, 310 
statistics of, 
310 
secondary deformities of, 

3 ? 8 . 
statistics of, 

310 

situation of, 304 

statistics of, 304, 305, 

306 

age, 305 

sex, 305 

age at incipiency, 
table of, 306 
symptoms of, 306 
synovial disease in, 318 
treatment of, 
318 
chloride of 
zinc in, 
318 
carbolic 
acid in, 
205, 318 
i o d o form 
injection 
in, 319 
venous sta- 
sis in, 205 
treatment of, 311 

conservative, 312 
during convales- 
cence, 317 
forcible correction 

in, 314 
mechanical, 314 
Thomas knee 
brace in, 
314 
description 
of, 315 
the caliper 
brace in, 
317 
description 
of, 317 
reduction of de- 
formity in, 
312 
by the plaster 
bandage, 313 
by traction, 313 



INDEX. 649 


Tuberculous disease of knee joint, reduc- 


Tuberculous disease of spine, middle re- 


tion of, by the Billroth splint, 


gion, symptoms of, 


313 


48 


of shoulder joint, 348 


treatment of, 90 


abscess in, 350 


paralysis in, 93 


pathology of, 348 


duration of, 95 


prognosis of, 350 


statistics of frequency 


results of, 350 


of, 93 


statistics, age at in- 


liability to, in dif- 


cipiency, table of, 


ferent regions, 94 


349 


prognosis of, 95 


statistics of frequency 


time of onset of, 95 


of, 348 


symptoms of, 95 


symptoms of, 349 


treatment of, 97 


treatment of, 350 


operative, 98 


operative, 350 


duration of, 99 


of spine, 17 


pathology of, 18 


at cervico-dorsal junction, 


physical signs of, 34 


53 


principles of treatment of, 80 


differential diag- 


prognosis of, 24 


nosis, 54 


rational signs of, 32 


complications of, 87 


record of, 57 


abscess, 87 


recurrence of, 100 


in different regions, 


regional examination in, 35 


88 


secondary deformities of, 100 


treatment of, 89 


statistics of, 21 


deformity of, 17 


age, 22 


effect of, 17 


frequency, 21 


diagnosis in general, 57 


sex, 22 


etiology of, 21 


situation, 22 


forcible correction, deform- 


symptoms of, 24 


ity of, 101 


diagnostic, 25 


Calot's opera- 


general, 29 


tion, 101 


secondary, 28 


statistics, re- 


treatment of, 58 


sults of, 102 


anterior shoulder brace 


selection of 


in, 66 


cases for, 102 


of the different regions, 


gradual correction, deform- 


special indications 


ity of, 104 


for, 83 


Metzger-Goldthwait 


horizontal fixation in, 60 


apparatus for, 105 


apparatus for, 


history of, 33 


60 ' 


local paralysis in, 98 


B radfor d 


lower cervical region, 52 


frame, 60 


lower region of, 35 


applica- 


characteristic atti- 


tion of, 


tude in, 35 


62 


differential diagno- 


Phelps' bed, 60 


sis of, 41 


reel in ati o n- 


increased lordosis 


gypsbet t e s, 


in, 35 


Lorenz, for, 


lateral inclination 


60 


of body in, 38 


wire cuirasse, 


location of pain in, 


. 60 


38 


jury mast in, 73 


pelvic abscess in, 


mechanical, general 


40 


principles of, 58 


treatment of, 90 


plaster jacket in, 70 


psoas contraction 


principles of, 80 


in, 36 


recumbency, indications 


lumbar, peculiarities of in 


for, 81 


infancy, 44 


Taylor brace in, 63 


middle region, 46 


measurements for. 


abscess in, 49 


64 


diagnosis of, 50 


application of, 64 



650 



INDEX. 



Tuberculous disease of spine, middle re- 
gion, Taylor head support 
in, 69 ' 
upper region, 51 

symptoms of, 52 
Thomas collar in, 79 
sub-astragaloid joint, 339 
diagnosis, 339 

differential, 339 
tarsus, 341 
disease of individual bones, 

statistics of, 341 
primary disease astragalo- 
scaphoid joint, 342 
prognosis, 342 
statistics of situation of, 

341 
treatment of, 342 
wrist joint, 354 

prognosis of, 355 
statistics of, 354 
age at incip- 
iency, table 
of, 355 
symptoms of, 345 
treatment of, 355 
caries sicca in, 201 
connective tissue in, 200 
deposit of fibrin in, 200 
diseases predisposing to, 195 
etiology of, 194 
extra-articular, 199 

abscess in, 199 
local predisposition to, 195 
influence of injury 
in, 195 
osteophytes in, 200 
pathology of, 198 
perforation of joint in, 200 
predisposition to, 194 
hereditary, 194 
acquired, 194 
prognosis of, 202 
repair in, 202 
rice bodies in, 201 
seat of, 196 

secondary abscess in, 200 
secondary changes in, 200 
septic infection in, 202 
statistics of, 196 
age, 197 

distribution, 196 
relative frequency, 197 
statistics of results of, 203 
sex, 197 

side affected, 197 
treatment of, 204 
by drugs, 204 
by local application, 204 
carbolic acid, 

205 
iodoform, 204 
venous stasis, 205 
■ ' white swelling ' ' in, 201 
teno-synovitis, 347 
Tumor albus, see Tuberculous Disease of 

Knee Joint, 304 
Typhoid fever, arthritis following, 211 



Typhoid spine, 110 

treatment of, 110 

UNILATERAL coxa vara, 396 
dislocation of hip, 378 
genu valgum, 415 
Upper extremity, deformities of, in an- 
terior poliomyelitis, 447 

VALGUS, traumatic, 624 
Vertebrae, absence of, 186 
Vertebral column, stiffness of, see Spon- 
dylitis Deformans, 111 
Volkmann's seat in lateral curvature of 
spine, 180 



W 



EAK foot, 507 

anatomy of, 508 
in childhood, 519 

out and in toeing as symp- 
toms of, 519 
diagnosis of, 514 
etiology of, 511 
extreme types of, 517 
pathology of, 511 
rigid, 527 

treatment of, 527 
adjuncts in, 532 

plaster strapping in, 
532 
forcible over-correction 

in, 527 
systematic manipulation 

in, 527 
Thomas, 532 
symptoms of, 513 
treatment of, 521 
attitudes in, 522 
brace in, 525 
exercises in, 523 
treatment, operative, 532 



support in, 523 
varieties of, 516 
Webbed fingers, 437 

etiology of, 437 
treatment of, 437 
Weight, table of, 190 
White swelling, see tuberculous disease 

of knee joint, 304 
Willett's operation for calcaneus, 619 
Wire cuirasse in treatment of Pott's dis- 
ease, 60 
Wolff's law, 190 

method of correction of confirmed 

club foot, 593 
treatment of genu valgum, 423 
Wrist, acute teno-synovitis at, 360 
congenital deformities at, 434 
joint, tuberculous disease of, 354 
sprain of, 359 
chronic, 359 

treatment of, 359 
treatment of, 359 
subluxation of, 434 
etiology of, 434 
treatment of, 434 
Wry neck, see torticollis, 474 



22 1801 



APR 11 1901 



